Healthcare Provider Details

I. General information

NPI: 1912443185
Provider Name (Legal Business Name): MRS. DALLAS MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S I 75 BUSINESS LOOP
GRAYLING MI
49738-2008
US

IV. Provider business mailing address

1599 W DOYLE TRL
ROSCOMMON MI
48653-9211
US

V. Phone/Fax

Practice location:
  • Phone: 989-889-1198
  • Fax:
Mailing address:
  • Phone: 844-854-1116
  • Fax: 305-846-9711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: