Healthcare Provider Details

I. General information

NPI: 1568956241
Provider Name (Legal Business Name): ERIC GAYLIN MART PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 LAFAYETTE RD STE 7
PORTSMOUTH NH
03801-5429
US

IV. Provider business mailing address

230 LAFAYETTE RD STE 7
PORTSMOUTH NH
03801-5429
US

V. Phone/Fax

Practice location:
  • Phone: 603-373-8801
  • Fax:
Mailing address:
  • Phone: 603-373-8801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number8194
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: