Provider Demographics
NPI:1003963786
Name:VAN DER VOORT, MARTHA (LPC)
Entity type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:
Last Name:VAN DER VOORT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARTIE
Other - Middle Name:
Other - Last Name:VAN DER VOORT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5401 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3143
Mailing Address - Country:US
Mailing Address - Phone:520-750-0594
Mailing Address - Fax:
Practice Address - Street 1:5401 E 10TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3143
Practice Address - Country:US
Practice Address - Phone:520-603-3204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC 2065101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional