Healthcare Provider Details

I. General information

NPI: 1346606886
Provider Name (Legal Business Name): NELIDA MARTIN LPC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. NELLIE MARTIN TILLMAN

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 BUFFALO GAP RD STE A2
ABILENE TX
79606-3361
US

IV. Provider business mailing address

4601 BUFFALO GAP RD STE A2
ABILENE TX
79606-3361
US

V. Phone/Fax

Practice location:
  • Phone: 325-704-2553
  • Fax: 325-701-9944
Mailing address:
  • Phone: 325-704-2553
  • Fax: 325-701-9944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number18921
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: