Healthcare Provider Details

I. General information

NPI: 1083912117
Provider Name (Legal Business Name): EBONIQUE MARTIN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2011
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 N PATTERSON ST STE B
VALDOSTA GA
31602-2577
US

IV. Provider business mailing address

805 HARMON DR APT B6
VALDOSTA GA
31601-8477
US

V. Phone/Fax

Practice location:
  • Phone: 229-232-4833
  • Fax: 877-343-0538
Mailing address:
  • Phone: 229-232-9061
  • Fax: 877-343-0538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001168
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: