Provider Demographics
NPI:1063562494
Name:MARTIN, RICHARD GRANT (MA,LPC,LMFT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GRANT
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MA,LPC,LMFT
Other - Prefix:MR
Other - First Name:RICK
Other - Middle Name:G
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LPC, LMFT
Mailing Address - Street 1:1232 SHEPPARD ST
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-3460
Mailing Address - Country:US
Mailing Address - Phone:318-469-9132
Mailing Address - Fax:318-377-9979
Practice Address - Street 1:1232 SHEPPARD ST
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-3460
Practice Address - Country:US
Practice Address - Phone:318-469-9132
Practice Address - Fax:318-377-9979
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA137106H00000X
LA2032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5469534Medicaid
LA1063562494OtherNPI