Healthcare Provider Details

I. General information

NPI: 1558961441
Provider Name (Legal Business Name): SAVANNA MARTIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 BROOKFIELD CORPORATE DR
CHANTILLY VA
20153-8001
US

IV. Provider business mailing address

4410 BROOKFIELD CORPORATE DR
CHANTILLY VA
20151-1662
US

V. Phone/Fax

Practice location:
  • Phone: 703-249-9976
  • Fax:
Mailing address:
  • Phone: 703-249-9976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPRC200001292
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14293149-6004
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701010674
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC.0017709
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: