MEDICARE: OLIVIA LONG MARTIN 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	2206	MS

General Provider Information

NPI Number	:	1558836080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA LONG MARTIN LPC

Provider Business Mailing Address
First Line	:	207 WATERFORD SQ STE 3
Second Line	:
City	:	MADISON
State	:	MS
Zip	:	39110-6881
Country	:	US
Telephone Number	:	601-751-4180
Fax Number	:	601-429-1186

Provider Business Practice Location Address
First Line	:	207 WATERFORD SQ STE 3
Second Line	:
City	:	MADISON
State	:	MS
Zip	:	39110-6881
Country	:	US
Telephone Number	:	601-751-4180
Fax Number	:	601-429-1186

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

Provider Enumeration Date	:	10/11/2018
Last Update Date	:	03/09/2026

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Directions to “ OLIVIA LONG MARTIN LPC” Practice Location

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