Basic Information
| Provider Information | |||||||||
| NPI: | 1710657614 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MISTY-LEE | ||||||||
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| Credential: | MS, LAPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 426 VALLEYSIDE DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301579373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708910917 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4255 WADE GREEN RD NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301441762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782132194 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2021 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | APC008124 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.