Basic Information
| Provider Information | |||||||||
| NPI: | 1497012264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC, LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RYAN | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC, LMFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 S MAIN ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721437801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012799000 | ||||||||
| FaxNumber: | 5012799011 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S MAIN ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721437801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012799000 | ||||||||
| FaxNumber: | 5012799011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2012 | ||||||||
| LastUpdateDate: | 02/20/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P1411099 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | M1411010 | AR | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.