Provider Demographics
NPI:1063958445
Name:MARTIN, GINA ADAMS (LPC)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:ADAMS
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 1:2604 BLUEBIRD LN
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-2307
Mailing Address - Country:US
Mailing Address - Phone:432-238-0597
Mailing Address - Fax:
Practice Address - Street 1:2604 BLUEBIRD LN
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-2307
Practice Address - Country:US
Practice Address - Phone:432-238-0597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67024101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional