Healthcare Provider Details

I. General information

NPI: 1255825295
Provider Name (Legal Business Name): PEPPER LEIGH MARTIN L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 PATRICK AVENUE
STUART VA
24171-2581
US

IV. Provider business mailing address

338 PATRICK AVENUE
STUART VA
24171
US

V. Phone/Fax

Practice location:
  • Phone: 276-693-3381
  • Fax:
Mailing address:
  • Phone: 276-693-3381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701007504
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number0701007504
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: