Provider Demographics
NPI:1669735353
Name:MARTIN, NICOLE KATHLEEN (LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:KATHLEEN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 LYNNE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3515
Mailing Address - Country:US
Mailing Address - Phone:215-364-1319
Mailing Address - Fax:215-672-1172
Practice Address - Street 1:696 SECOND STREET PIKE
Practice Address - Street 2:SUITE 201
Practice Address - City:RICHBORO
Practice Address - State:PA
Practice Address - Zip Code:18954-1068
Practice Address - Country:US
Practice Address - Phone:215-504-9423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC006359101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional