MEDICARE: MS. MARTHA VAN DER VOORT LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC 2065	AZ

General Provider Information

NPI Number	:	1003963786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARTHA VAN DER VOORT LPC

Provider Business Mailing Address
First Line	:	5401 E 10TH ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-3143
Country	:	US
Telephone Number	:	520-750-0594
Fax Number	:

Provider Business Practice Location Address
First Line	:	5401 E 10TH ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-3143
Country	:	US
Telephone Number	:	520-603-3204
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	07/08/2007

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