Healthcare Provider Details

I. General information

NPI: 1407582166
Provider Name (Legal Business Name): CAROL JEAN MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAROL JEAN MARTIN-NELSON

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LAFAYETTE ST STE 140B
GRETNA LA
70053-5762
US

IV. Provider business mailing address

1500 LAFAYETTE ST STE 140B
GRETNA LA
70053-5762
US

V. Phone/Fax

Practice location:
  • Phone: 504-533-9152
  • Fax: 504-533-9154
Mailing address:
  • Phone: 504-533-9152
  • Fax: 504-533-9154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: