Stephanie Ailis Martin
Individual provider Active NPI Mental Health Counselor · Bullock, NC
NPI 1487430757 · NPPES record last updated Sep 4, 2023
Key facts
- NPI
- 1487430757
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Mental Health Counselor 101YM0800X
- License
- P018296 (NC)
- Practice address
- 9553 Whippoorwill Ridge Rd
Bullock, NC 27507-9362 - Phone
- (434) 774-5505
- NPI assigned
- Sep 4, 2023
- Sex
- Female
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare Care Compare profile
- Specialty
- Clinical Social Worker
- Education
- Boston University School of Medicine, 2022
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Southside Behavioral Health
Practice addresses (Care Compare)
424 Hamilton Blvd
South Boston, VA 24592-5200
Phone (434) 572-2936
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in VA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: No · Power mobility devices: No · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20260401003040 | VA | Practitioner - Clinical Social Worker | 2668957101 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LCAS-29171 | NC | MD | Addiction (Substance Use Disorder) Counselor |
| P018296 | NC | MD | Mental Health Counselor |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | LCAS-29171 | NC | |
| Mental Health Counselor | 101YM0800X | P018296 | NC | Yes |
Addresses
Primary practice location
9553 Whippoorwill Ridge Rd
Bullock, NC 27507-9362
Mailing address
9553 Whippoorwill Ridge Rd
Bullock, NC 27507-9362
Phone (434) 774-5505
Other providers in Bullock, NC
All providers in Bullock, NC · Mental Health Counselor in North Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 4, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.