Provider Demographics
NPI:1255016689
Name:MARTIN, MIA NICOLE
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:NICOLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 DULAIRE RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-5943
Mailing Address - Country:US
Mailing Address - Phone:336-549-3004
Mailing Address - Fax:
Practice Address - Street 1:2610 FOUR SEASONS BLVD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-6025
Practice Address - Country:US
Practice Address - Phone:336-294-7335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool