Healthcare Provider Details

I. General information

NPI: 1669417630
Provider Name (Legal Business Name): LARRY RAY MARTENS LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 HIGHWAY 65 NORTH
MARSHALL AR
72650
US

IV. Provider business mailing address

517 BRADLEY RIDGE ROAD
MADSHALL AR
72650
US

V. Phone/Fax

Practice location:
  • Phone: 870-448-4727
  • Fax: 870-448-4496
Mailing address:
  • Phone: 870-496-2707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA0607045
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: