Healthcare Provider Details

I. General information

NPI: 1407071731
Provider Name (Legal Business Name): CHARLES ROCHELLE MARTIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 NW 43RD ST SUITE E-4
GAINESVILLE FL
32606-8137
US

IV. Provider business mailing address

3600 NW 43RD ST E-4
GAINESVILLE FL
32606-8137
US

V. Phone/Fax

Practice location:
  • Phone: 352-375-7756
  • Fax:
Mailing address:
  • Phone: 352-375-7756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY5214
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: