Provider Demographics
NPI:1689110660
Name:MARTIN, TAISHA (LCPC, NCC)
Entity Type:Individual
Prefix:
First Name:TAISHA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E TOWSONTOWN BLVD
Mailing Address - Street 2:SUITE 2W
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5318
Mailing Address - Country:US
Mailing Address - Phone:410-296-2004
Mailing Address - Fax:410-296-0094
Practice Address - Street 1:320 E TOWSONTOWN BLVD
Practice Address - Street 2:SUITE 2W
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286
Practice Address - Country:US
Practice Address - Phone:410-296-2004
Practice Address - Fax:410-296-0094
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7360101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD116647600Medicaid