Provider Demographics
NPI:1972711042
Name:MARTIN, MARY CATHERINE (MA,MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CATHERINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA,MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 503010
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-0813
Mailing Address - Country:US
Mailing Address - Phone:541-941-7792
Mailing Address - Fax:503-419-4662
Practice Address - Street 1:3550 NATIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-941-9246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLPC1361101YP2500X
ORLPC3061106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional