Provider Demographics
NPI:1932361318
Name:MARTIN, JOHN GARY (MED, LPC, LPCS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:GARY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MED, LPC, LPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S MCQUEEN ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4722
Mailing Address - Country:US
Mailing Address - Phone:843-673-0054
Mailing Address - Fax:843-667-1549
Practice Address - Street 1:323 S MCQUEEN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4722
Practice Address - Country:US
Practice Address - Phone:843-673-0054
Practice Address - Fax:843-667-1549
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC326101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional