Provider Demographics
NPI:1972960342
Name:MARTENS, RUSSELL (LPC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:MARTENS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 MARIE LN
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3865
Mailing Address - Country:US
Mailing Address - Phone:303-335-5573
Mailing Address - Fax:
Practice Address - Street 1:4025 RAWLINS ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1900
Practice Address - Country:US
Practice Address - Phone:307-426-4797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-1669101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYLPC-1669OtherWYOMING MENTAL HEALTH PROFESSIONS LICENSE