MEDICARE: MIA MARTINSON M.ED, NCC, 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
2	101YP2500X	Professional Counselor	8515	SC

General Provider Information

NPI Number	:	1972119543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA MARTINSON M.ED, NCC, LPC

Provider Business Mailing Address
First Line	:	200 N MAIN ST STE 300A
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-5110
Country	:	US
Telephone Number	:	865-458-8176
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 N MAIN ST STE 300A
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-5110
Country	:	US
Telephone Number	:	865-458-8176
Fax Number	:

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

Provider Enumeration Date	:	09/19/2020
Last Update Date	:	03/15/2023

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