Provider Demographics
NPI:1669417630
Name:MARTENS, LARRY RAY (LAC)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:RAY
Last Name:MARTENS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 BRADLEY RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:MADSHALL
Mailing Address - State:AR
Mailing Address - Zip Code:72650
Mailing Address - Country:US
Mailing Address - Phone:870-496-2707
Mailing Address - Fax:
Practice Address - Street 1:316 HIGHWAY 65 NORTH
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:AR
Practice Address - Zip Code:72650
Practice Address - Country:US
Practice Address - Phone:870-448-4727
Practice Address - Fax:870-448-4496
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0607045101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health