Healthcare Provider Details

I. General information

NPI: 1619742103
Provider Name (Legal Business Name): PAUL PHILLIP MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2023
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W WEST ST
BALTIMORE MD
21230-3739
US

IV. Provider business mailing address

140 W WEST ST
BALTIMORE MD
21230-3739
US

V. Phone/Fax

Practice location:
  • Phone: 410-752-4454
  • Fax:
Mailing address:
  • Phone: 410-752-4454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC1841
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: