Healthcare Provider Details

I. General information

NPI: 1053230714
Provider Name (Legal Business Name): NICHOLAS MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 E BELL RD STE 163
PHOENIX AZ
85032-9382
US

IV. Provider business mailing address

4550 E BELL RD STE 163
PHOENIX AZ
85032-9382
US

V. Phone/Fax

Practice location:
  • Phone: 480-590-2783
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBEH-002134
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: