Healthcare Provider Details

I. General information

NPI: 1790664456
Provider Name (Legal Business Name): MR. EDDIE MARTIN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7130 MINSTREL WAY STE 125
COLUMBIA MD
21045-5329
US

IV. Provider business mailing address

12946 GRIFFIN CIR
CLARKSBURG MD
20871-9245
US

V. Phone/Fax

Practice location:
  • Phone: 443-927-7797
  • Fax:
Mailing address:
  • Phone: 205-454-3654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: