Healthcare Provider Details

I. General information

NPI: 1619246998
Provider Name (Legal Business Name): REBECCA A MARTIN LCPC-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 SCHOOL ST
RANDOLPH ME
04346-5146
US

IV. Provider business mailing address

28 SCHOOL ST
RANDOLPH ME
04346-5146
US

V. Phone/Fax

Practice location:
  • Phone: 207-629-7025
  • Fax:
Mailing address:
  • Phone: 207-629-7025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberXL3890
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: