Provider Demographics
NPI:1285911545
Name:TOLBERT-MARTIN, AUDRA D (LPC-SUPERVISION)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:D
Last Name:TOLBERT-MARTIN
Suffix:
Gender:F
Credentials:LPC-SUPERVISION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 PEARCE DR
Mailing Address - Street 2:
Mailing Address - City:POTTSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75076-7067
Mailing Address - Country:US
Mailing Address - Phone:646-246-3010
Mailing Address - Fax:
Practice Address - Street 1:715 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3801
Practice Address - Country:US
Practice Address - Phone:580-931-3008
Practice Address - Fax:580-931-8022
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid