Provider Demographics
NPI:1265730238
Name:MARTIN, LATASHA (EDS, LPC)
Entity type:Individual
Prefix:MRS
First Name:LATASHA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:EDS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136-4 FORUM DRIVE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229
Mailing Address - Country:US
Mailing Address - Phone:803-200-2333
Mailing Address - Fax:803-877-1036
Practice Address - Street 1:136-4 FORUM DRIVE
Practice Address - Street 2:SUITE 170
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229
Practice Address - Country:US
Practice Address - Phone:803-200-2333
Practice Address - Fax:803-877-1036
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5243101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor