Healthcare Provider Details

I. General information

NPI: 1053509059
Provider Name (Legal Business Name): GREGORY JOHN MARTIN LMHC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 SUSIE WILSON RD
ESSEX JUNCTION VT
05452-2808
US

IV. Provider business mailing address

64 SUSIE WILSON RD
ESSEX JUNCTION VT
05452-2808
US

V. Phone/Fax

Practice location:
  • Phone: 802-363-3220
  • Fax:
Mailing address:
  • Phone: 802-363-3220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number068-0000704
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: