Healthcare Provider Details

I. General information

NPI: 1609220896
Provider Name (Legal Business Name): MARY MARTIN LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 S STEPHANIE ST STE B
HENDERSON NV
89012-4423
US

IV. Provider business mailing address

2950 N GREEN VALLEY PKWY APT 924
HENDERSON NV
89014-0428
US

V. Phone/Fax

Practice location:
  • Phone: 702-530-4471
  • Fax:
Mailing address:
  • Phone: 702-530-4471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCP6255
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: