Healthcare Provider Details

I. General information

NPI: 1104676006
Provider Name (Legal Business Name): MARTHA MITCHELL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 07/05/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 GRANITE AVE
BILLINGS MT
59102-0716
US

IV. Provider business mailing address

1412 GRANITE AVE
BILLINGS MT
59102-0716
US

V. Phone/Fax

Practice location:
  • Phone: 619-997-7454
  • Fax:
Mailing address:
  • Phone: 619-997-7454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8435
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: