Provider Demographics
NPI:1538710132
Name:MARTIN, NICOLE RENEE (LGPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5902 31ST AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-2903
Mailing Address - Country:US
Mailing Address - Phone:828-577-2292
Mailing Address - Fax:
Practice Address - Street 1:5902 31ST AVE APT 203
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-2903
Practice Address - Country:US
Practice Address - Phone:828-577-2292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9860101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health