Basic Information
| Provider Information | |||||||||
| NPI: | 1285911545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOLBERT-MARTIN | ||||||||
| FirstName: | AUDRA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LPC-SUPERVISION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1381 PEARCE DR | ||||||||
| Address2: | |||||||||
| City: | POTTSBORO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750767067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6462463010 | ||||||||
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| Practice Location | |||||||||
| Address1: | 715 N 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747013801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809313008 | ||||||||
| FaxNumber: | 5809318022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2011 | ||||||||
| LastUpdateDate: | 11/14/2011 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 200049040 | 05 | OK | MEDICAID |