Doctor Name: | MRS. PETREA MARY MARTIN |
NPI Number: | 1255665857 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LCPC |
License Number: | 1159-LCPC |
Business Practice Address: | 400 4th Avenue West Poplar, MT - 59255 |
Business Phone Number: | 4067686763 |
Business Fax Number: | 4067686802 |
Mailing Address: | 14419 County Road 323, BROCKTON |
State: | MT |
Postal Code: | 592139510 |
Phone Number: | 4067875500 |
Fax Number: | 4067875500 |
NPI Enumeration Date: | 09/29/2009 |
NPI Last Update Date: | 09/29/2009 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | 1159-LCPC |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MT |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |