Provider Demographics
NPI:1104119734
Name:MARTIN, JULIE GODDARD (LMHC)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:GODDARD
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 W SPRUCE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2346
Mailing Address - Country:US
Mailing Address - Phone:813-636-8811
Mailing Address - Fax:813-636-8855
Practice Address - Street 1:4107 W SPRUCE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2327
Practice Address - Country:US
Practice Address - Phone:813-636-8811
Practice Address - Fax:813-636-8855
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11025101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10543400Medicaid
FL012377300OtherGROUP MEDICAID NUMBER