Provider Demographics
NPI:1386380954
Name:MARTYN, DEIRDRE LEE (LPA HSP-PA)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:LEE
Last Name:MARTYN
Suffix:
Gender:F
Credentials:LPA HSP-PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 WIGEON WAY
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27596-6503
Mailing Address - Country:US
Mailing Address - Phone:717-725-0343
Mailing Address - Fax:
Practice Address - Street 1:10580 LIGON MILL RD
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6090
Practice Address - Country:US
Practice Address - Phone:919-263-9592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6086103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool