Healthcare Provider Details

I. General information

NPI: 1669532123
Provider Name (Legal Business Name): ALBERT A. MARTIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 E 86TH AVE
MERRILLVILLE IN
46410-6211
US

IV. Provider business mailing address

150 PARKVIEW AVE
LOWELL IN
46356-2209
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-3868
  • Fax: 219-696-8569
Mailing address:
  • Phone: 219-696-7280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20010344A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: