Provider Demographics
NPI:1699099572
Name:FENNELL, MARTHA HARRELL (LMFT)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:HARRELL
Last Name:FENNELL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1646
Mailing Address - Country:US
Mailing Address - Phone:478-361-2601
Mailing Address - Fax:
Practice Address - Street 1:265 ORANGE ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1646
Practice Address - Country:US
Practice Address - Phone:478-361-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-21
Last Update Date:2010-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001148106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist