Provider Demographics
NPI:1629478276
Name:MARTIN, LAMONT
Entity Type:Individual
Prefix:
First Name:LAMONT
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 GOLF LAKES TRL
Mailing Address - Street 2:1035
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-5029
Mailing Address - Country:US
Mailing Address - Phone:214-735-8299
Mailing Address - Fax:
Practice Address - Street 1:9600 GOLF LAKES TRL
Practice Address - Street 2:1035
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5029
Practice Address - Country:US
Practice Address - Phone:214-735-8299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12476101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)