Provider Demographics
NPI:1134537301
Name:VAN DAM, MARTHA LAWSON (MS, NCC)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:LAWSON
Last Name:VAN DAM
Suffix:
Gender:F
Credentials:MS, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 WINDWARD WAY
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4328
Mailing Address - Country:US
Mailing Address - Phone:850-687-5105
Mailing Address - Fax:
Practice Address - Street 1:151 MARY ESTHER BLVD
Practice Address - Street 2:SUITE 507
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1972
Practice Address - Country:US
Practice Address - Phone:850-226-7419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15174101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health