Healthcare Provider Details

I. General information

NPI: 1497904312
Provider Name (Legal Business Name): LAKE MARTIN FAMILY THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 GREEN ST
ALEXANDER CITY AL
35010-1407
US

IV. Provider business mailing address

PO BOX 911
ALEXANDER CITY AL
35011-0911
US

V. Phone/Fax

Practice location:
  • Phone: 256-625-9514
  • Fax: 256-825-6418
Mailing address:
  • Phone: 256-625-9514
  • Fax: 256-825-6418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2121C
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberL 299
License Number StateAL

VIII. Authorized Official

Name: KAREN C. LEWIS
Title or Position: MEMBER/OWNER
Credential: LMFT, LCSW
Phone: 256-625-9514