Healthcare Provider Details

I. General information

NPI: 1235883646
Provider Name (Legal Business Name): STEFANIE NICOLE MARTIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2022
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

IV. Provider business mailing address

4530 GLASTONBURY DR
EVANS GA
30809-8217
US

V. Phone/Fax

Practice location:
  • Phone: 706-790-2011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC013561
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: