Provider Demographics
NPI:1538265699
Name:MARTIN, CHERYL (LPC)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
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:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4560
Mailing Address - Fax:520-682-4570
Practice Address - Street 1:13549 N SANDERS RD
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653
Practice Address - Country:US
Practice Address - Phone:520-682-1091
Practice Address - Fax:520-682-4132
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCP-11076101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ116645Medicaid