Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | P016318 | NC |
N | 106S00000X | Behavior Technician | NC |
NPI | 1003381203 |
---|---|
Provider Name | Nicolla Martin |
First Address | Charlotte, NC 28211-1118 |
Second Address | Charlotte, NC 28211-1118 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2018 |
Last Update Date | 10/09/2021 |