Provider Demographics
NPI:1194906396
Name:MARTIN, NICOLE L (LPC)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:L
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 1:6915 CRUMPLER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1907
Mailing Address - Country:US
Mailing Address - Phone:601-500-1132
Mailing Address - Fax:
Practice Address - Street 1:6915 CRUMPLER BLVD STE A
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1907
Practice Address - Country:US
Practice Address - Phone:601-500-1132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health