Healthcare Provider Details

I. General information

NPI: 1740448034
Provider Name (Legal Business Name): TYRIS ALAINNA MARTIN M.A,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TY ALAINNA MARTIN LPC

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

IV. Provider business mailing address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-9904
  • Fax:
Mailing address:
  • Phone: 314-206-3718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2010018203
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: