Provider Demographics
NPI:1750542544
Name:MARTIN, LARRY W
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:MARTIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 HANBURY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-3013
Mailing Address - Country:US
Mailing Address - Phone:803-786-2282
Mailing Address - Fax:
Practice Address - Street 1:2638 TWO NOTCH RD
Practice Address - Street 2:SUITE 106 INSIGHTS PROGRAM
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1432
Practice Address - Country:US
Practice Address - Phone:803-898-0204
Practice Address - Fax:803-779-2362
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health