Healthcare Provider Details

I. General information

NPI: 1821491051
Provider Name (Legal Business Name): AMBER MARIE MARTIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 03/20/2023
Certification Date: 03/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHESTNUT STREET
SUMMIT MS
39666
US

IV. Provider business mailing address

617 W NEW YORK AVE
MCCOMB MS
39648-3201
US

V. Phone/Fax

Practice location:
  • Phone: 601-395-0261
  • Fax: 601-299-9012
Mailing address:
  • Phone: 601-395-0261
  • Fax: 601-600-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2147
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: