Provider Demographics
NPI:1649485913
Name:WARD, MARTHA LYN (LPC, ATR)
Entity type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:LYN
Last Name:WARD
Suffix:
Gender:F
Credentials:LPC, ATR
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:LYN
Other - Last Name:CONNALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 BLUFF ROAD
Mailing Address - Street 2:
Mailing Address - City:FISCHER
Mailing Address - State:TX
Mailing Address - Zip Code:78623
Mailing Address - Country:US
Mailing Address - Phone:210-737-2674
Mailing Address - Fax:210-734-2412
Practice Address - Street 1:282 OLD KYLE ROAD
Practice Address - Street 2:
Practice Address - City:WIMBERLY
Practice Address - State:TX
Practice Address - Zip Code:78676
Practice Address - Country:US
Practice Address - Phone:210-737-2674
Practice Address - Fax:210-734-2412
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12042101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0954307-03Medicaid