Healthcare Provider Details

I. General information

NPI: 1538283031
Provider Name (Legal Business Name): NICOLE GREGORY MARTIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 E SOTHEL ST SUITE 6
KILL DEVIL HILLS NC
27948-6961
US

IV. Provider business mailing address

300 E DRIFTWOOD ST
NAGS HEAD NC
27959-9173
US

V. Phone/Fax

Practice location:
  • Phone: 252-207-3701
  • Fax: 252-441-3057
Mailing address:
  • Phone: 252-207-3701
  • Fax: 252-441-3057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4519
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: