Basic Information
| Provider Information | |||||||||
| NPI: | 1427322312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | KARLA | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 ARSENAL AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103233368 | ||||||||
| FaxNumber: | 9104867000 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 ARSENAL AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103233368 | ||||||||
| FaxNumber: | 9104867000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2012 | ||||||||
| LastUpdateDate: | 01/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 9732 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 9732 | NC | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.