1689110660 NPI number — TAISHA MARTIN LCPC, NCC

Table of content: TAISHA MARTIN LCPC, NCC (NPI 1689110660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689110660 NPI number — TAISHA MARTIN LCPC, NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
TAISHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC, NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689110660
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 E TOWSONTOWN BLVD
Provider Second Line Business Mailing Address:
SUITE 2W
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21286-5318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-296-2004
Provider Business Mailing Address Fax Number:
410-296-0094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 E TOWSONTOWN BLVD
Provider Second Line Business Practice Location Address:
SUITE 2W
Provider Business Practice Location Address City Name:
TOWSON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-296-2004
Provider Business Practice Location Address Fax Number:
410-296-0094
Provider Enumeration Date:
01/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LC7360 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 116647600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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