MEDICARE: STACY MARTIN LPC, LAC, CACI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	454	SC
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	1802226	SC
3	101YP2500X	Professional Counselor	6779	SC

General Provider Information

NPI Number	:	1407239585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY MARTIN LPC, LAC, CACI

Provider Business Mailing Address
First Line	:	301 HALTON RD STE F
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-3498
Country	:	US
Telephone Number	:	864-479-4226
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 HALTON RD STE F
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-3498
Country	:	US
Telephone Number	:	864-479-4226
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	08/14/2023

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