Healthcare Provider Details

I. General information

NPI: 1538317789
Provider Name (Legal Business Name): VICKI D MARTIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 MARKET ST
HORSESHOE BEND AR
72512-3871
US

IV. Provider business mailing address

2510 CRESCENT DR
HORSESHOE BEND AR
72512-5576
US

V. Phone/Fax

Practice location:
  • Phone: 870-351-6100
  • Fax: 870-750-2199
Mailing address:
  • Phone: 870-351-6100
  • Fax: 870-750-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1109069
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: