Healthcare Provider Details

I. General information

NPI: 1790941557
Provider Name (Legal Business Name): CHARLES ROBERT MARTIN LMFT LMHC NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 CHERRY ST ST MARYS MINISTRY CENTER
EVANSVILLE IN
47713-1807
US

IV. Provider business mailing address

613 CHERRY ST ST MARYS MINISTRY CENTER
EVANSVILLE IN
47713-1807
US

V. Phone/Fax

Practice location:
  • Phone: 812-425-1577
  • Fax: 812-426-1416
Mailing address:
  • Phone: 812-425-1577
  • Fax: 812-426-1416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000879A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35000349A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: