Provider Demographics
NPI:1790982056
Name:MARTIN, JOHN AUBREY (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:AUBREY
Last Name:MARTIN
Suffix:
Gender:M
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 1:13512 DANSVILLE DR
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28134-8111
Mailing Address - Country:US
Mailing Address - Phone:704-907-2898
Mailing Address - Fax:704-377-3182
Practice Address - Street 1:510 S TORRENCE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3160
Practice Address - Country:US
Practice Address - Phone:704-907-2898
Practice Address - Fax:704-377-3182
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPC #4441101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103177Medicaid