Provider Demographics
NPI:1710657614
Name:MARTIN, MISTY-LEE K (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MISTY-LEE
Middle Name:K
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 VALLEYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-9373
Mailing Address - Country:US
Mailing Address - Phone:770-891-0917
Mailing Address - Fax:
Practice Address - Street 1:4255 WADE GREEN RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1762
Practice Address - Country:US
Practice Address - Phone:678-213-2194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014096101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty