Healthcare Provider Details

I. General information

NPI: 1932605565
Provider Name (Legal Business Name): EDWINA LATASHA MARTIN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EDWINA LATASHA REECE PH.D.

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 03/09/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368-5142
US

IV. Provider business mailing address

PSC 80 BOX 20501
APO AP
96367-0090
US

V. Phone/Fax

Practice location:
  • Phone: 315-634-3272
  • Fax:
Mailing address:
  • Phone: 707-580-0105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35204
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: