MEDICARE: MARTINA TIMESHA BOULWARE 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	10935	SC

General Provider Information

NPI Number	:	1306669098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTINA TIMESHA BOULWARE LPC

Provider Business Mailing Address
First Line	:	840 CREEK BLUFF RD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-8267
Country	:	US
Telephone Number	:	803-448-5778
Fax Number	:

Provider Business Practice Location Address
First Line	:	840 CREEK BLUFF RD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-8267
Country	:	US
Telephone Number	:	803-448-5778
Fax Number	:

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

Provider Enumeration Date	:	11/01/2024
Last Update Date	:	04/30/2025

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Directions to “ MARTINA TIMESHA BOULWARE LPC” Practice Location

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