Provider Demographics
NPI:1659034650
Name:MARTIN, MICHELE RENEE (LPC)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:RENEE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 WOODS EDGE CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4358
Mailing Address - Country:US
Mailing Address - Phone:757-275-3739
Mailing Address - Fax:
Practice Address - Street 1:7460 TIDEWATER DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-3845
Practice Address - Country:US
Practice Address - Phone:757-664-6670
Practice Address - Fax:757-664-6676
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-16
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701010857101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701010857OtherBOARD OF COUNSELING