Healthcare Provider Details

I. General information

NPI: 1891270641
Provider Name (Legal Business Name): SHAYLA R MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20020-7715
US

IV. Provider business mailing address

4310 22ND ST NE
WASHINGTON DC
20018-3147
US

V. Phone/Fax

Practice location:
  • Phone: 202-724-7666
  • Fax:
Mailing address:
  • Phone: 704-942-4601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGPC00273
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: