Provider Demographics
NPI:1104060094
Name:MARTIN, ROGER (LPC)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16433 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:TX
Mailing Address - Zip Code:79758-4040
Mailing Address - Country:US
Mailing Address - Phone:432-561-8141
Mailing Address - Fax:432-550-3005
Practice Address - Street 1:1512 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-3044
Practice Address - Country:US
Practice Address - Phone:432-550-3001
Practice Address - Fax:432-550-3005
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61692101YA0400X, 101YM0800X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist