Provider Demographics
NPI:1821846387
Name:MARTIN, MADELON SULLIVAN (LPC, RPT)
Entity type:Individual
Prefix:
First Name:MADELON
Middle Name:SULLIVAN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC, RPT
Other - Prefix:
Other - First Name:MADELON
Other - Middle Name:PENNY
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC, RPT
Mailing Address - Street 1:6952 DOGWOOD MNR N
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-2090
Mailing Address - Country:US
Mailing Address - Phone:662-874-5232
Mailing Address - Fax:
Practice Address - Street 1:6952 DOGWOOD MNR N
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-2090
Practice Address - Country:US
Practice Address - Phone:662-874-5232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1345101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional