Basic Information
| Provider Information | |||||||||
| NPI: | 1538317789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 N WALTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727124576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792716302 | ||||||||
| FaxNumber: | 4792716307 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 MOCKINGBIRD LN | ||||||||
| Address2: | STE B & C | ||||||||
| City: | PARAGOULD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724505806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702400671 | ||||||||
| FaxNumber: | 8702400514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2008 | ||||||||
| LastUpdateDate: | 11/11/2011 | ||||||||
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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 | 101Y00000X | A0802007 | AR | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.