Provider Demographics
NPI:1245350545
Name:MARTIN, BAMBI RAE (LPC)
Entity type:Individual
Prefix:
First Name:BAMBI
Middle Name:RAE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W. MAIN
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080
Mailing Address - Country:US
Mailing Address - Phone:405-527-1785
Mailing Address - Fax:405-527-1084
Practice Address - Street 1:314 S. BROADWAY
Practice Address - Street 2:SUITE 106
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820
Practice Address - Country:US
Practice Address - Phone:580-235-0210
Practice Address - Fax:580-235-0211
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OK3849101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health