Healthcare Provider Details

I. General information

NPI: 1316718760
Provider Name (Legal Business Name): GILBERT T MARTIN III LPC-SA, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 01/15/2024
Certification Date: 01/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 LINCOLN ST
WEST MONROE LA
71291-4510
US

IV. Provider business mailing address

101 TRACE WEST RD
WEST MONROE LA
71291-9145
US

V. Phone/Fax

Practice location:
  • Phone: 318-816-8427
  • Fax:
Mailing address:
  • Phone: 318-816-8427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1203
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number453
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: