Healthcare Provider Details

I. General information

NPI: 1518208651
Provider Name (Legal Business Name): LUISA RAVEICA MARTIN LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S COLLEGE RD
WILMINGTON NC
28403-5545
US

IV. Provider business mailing address

2222 S COLLEGE RD
WILMINGTON NC
28403-5545
US

V. Phone/Fax

Practice location:
  • Phone: 910-798-6400
  • Fax:
Mailing address:
  • Phone: 910-798-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10061
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: