Healthcare Provider Details

I. General information

NPI: 1376242826
Provider Name (Legal Business Name): DOUGLAS R MARTINSON LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 05/24/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 RIVER ST STE 306
HOBOKEN NJ
07030-5619
US

IV. Provider business mailing address

499 PALISADE AVE APT 2
JERSEY CITY NJ
07307-1497
US

V. Phone/Fax

Practice location:
  • Phone: 201-565-2275
  • Fax:
Mailing address:
  • Phone: 732-510-9389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC01266700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: