Provider Demographics
NPI:1285291146
Name:AJAYI, MARTIN (LLPC)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:AJAYI
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 W MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1209
Mailing Address - Country:US
Mailing Address - Phone:269-312-8686
Mailing Address - Fax:561-282-3238
Practice Address - Street 1:1400 W MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1209
Practice Address - Country:US
Practice Address - Phone:269-312-8686
Practice Address - Fax:561-282-3238
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017108101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional