MEDICARE: MATTHEW MARTIN LPC

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	101YP2500X	Professional Counselor	0701011046	VA

General Provider Information

NPI Number	:	1962147553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW MARTIN LPC

Provider Business Mailing Address
First Line	:	3030 S COLLEGE AVE UNIT 207
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-2557
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 S COLLEGE AVE UNIT 207
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-2557
Country	:	US
Telephone Number	:	970-230-3770
Fax Number	:

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

Provider Enumeration Date	:	04/28/2022
Last Update Date	:	07/27/2022

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