Provider Demographics
NPI:1922403559
Name:MARTIN, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:MARIE
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCA, NCC, MS
Mailing Address - Street 1:1923 J N PEASE PLACE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262
Mailing Address - Country:US
Mailing Address - Phone:704-733-9700
Mailing Address - Fax:704-733-9298
Practice Address - Street 1:1932 J N PEASE PLACE
Practice Address - Street 2:SUITE 104
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262
Practice Address - Country:US
Practice Address - Phone:704-733-9700
Practice Address - Fax:704-733-9298
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA9874101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor