Basic Information
| Provider Information | |||||||||
| NPI: | 1386380954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTYN | ||||||||
| FirstName: | DEIRDRE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | LPA HSP-PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 WIGEON WAY | ||||||||
| Address2: | |||||||||
| City: | YOUNGSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275966503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177250343 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10580 LIGON MILL RD | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275876090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192639592 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2022 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 6086 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.