Provider Demographics
NPI:1679228720
Name:MARTIN, LORI SUZANNE (LADAC II, NCAC II)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:SUZANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LADAC II, NCAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 CALDERWOOD HWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-0823
Mailing Address - Country:US
Mailing Address - Phone:865-776-4354
Mailing Address - Fax:
Practice Address - Street 1:810 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:LOUDON
Practice Address - State:TN
Practice Address - Zip Code:37774-1309
Practice Address - Country:US
Practice Address - Phone:865-657-9303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDC0000000672101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)