Provider Demographics
NPI:1619693579
Name:MARTIN, LEE CUSTER (LPC, MS,ED)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:CUSTER
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC, MS,ED
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:CUSTER
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC, MS,ED
Mailing Address - Street 1:525 NORTHRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-1753
Mailing Address - Country:US
Mailing Address - Phone:610-613-1074
Mailing Address - Fax:
Practice Address - Street 1:525 NORTHRIDGE RD
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-1753
Practice Address - Country:US
Practice Address - Phone:610-613-1074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC014555101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional