Provider Demographics
NPI:1679699920
Name:MARTIN, LAURIE M
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1596 PEACEFUL LN N
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-1705
Mailing Address - Country:US
Mailing Address - Phone:248-891-2607
Mailing Address - Fax:
Practice Address - Street 1:89 W SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085
Practice Address - Country:US
Practice Address - Phone:248-891-2607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361000315103T00000X
MI6401008033101Y00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor