Provider Demographics
NPI:1427319052
Name:MARTIN, LISA MARIE GODFREY (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE GODFREY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1533
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-1908
Mailing Address - Country:US
Mailing Address - Phone:509-856-4998
Mailing Address - Fax:
Practice Address - Street 1:206 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3002
Practice Address - Country:US
Practice Address - Phone:509-201-1616
Practice Address - Fax:844-755-6412
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY 60253453103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical