1124261102 NPI number — MISS SUSAN LYNN MARTIN MA, LPC

Table of content: MISS SUSAN LYNN MARTIN MA, LPC (NPI 1124261102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124261102 NPI number — MISS SUSAN LYNN MARTIN MA, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
SUSAN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124261102
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1746
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-854-0110
Provider Business Mailing Address Fax Number:
928-854-0112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2277 SWANSON AVE.
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-854-0110
Provider Business Practice Location Address Fax Number:
928-854-0112
Provider Enumeration Date:
04/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LPC-13205 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC-13205 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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