Provider Demographics
NPI:1043009913
Name:MARTIN, PATRICE LARAE (LPCA)
Entity type:Individual
Prefix:MRS
First Name:PATRICE
Middle Name:LARAE
Last Name:MARTIN
Suffix:
Gender:
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 TALCOTTVILLE RD APT 80
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-2334
Mailing Address - Country:US
Mailing Address - Phone:860-804-8599
Mailing Address - Fax:
Practice Address - Street 1:151 STORRS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1638
Practice Address - Country:US
Practice Address - Phone:860-465-5960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6333101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor