Provider Demographics
NPI:1124261102
Name:MARTIN, SUSAN LYNN (MA, LPC)
Entity type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1746
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405
Mailing Address - Country:US
Mailing Address - Phone:928-854-0110
Mailing Address - Fax:928-854-0112
Practice Address - Street 1:2277 SWANSON AVE.
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-854-0110
Practice Address - Fax:928-854-0112
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-13205101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health