Basic Information
| Provider Information | |||||||||
| NPI: | 1356569487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LLP, LPC, LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 24670 LARGES DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480343220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483565282 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2550 S TELEGRAPH RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | BLOOMFIELD HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483020950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483220001 | ||||||||
| FaxNumber: | 2483220004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401001795 | MI | X | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 6301008167 | MI | X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.