Healthcare Provider Details

I. General information

NPI: 1174694558
Provider Name (Legal Business Name): GREGG A MARTIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 03/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 BELPAR ST NW
CANTON OH
44718-3603
US

IV. Provider business mailing address

4760 BELPAR ST NW
CANTON OH
44718-3603
US

V. Phone/Fax

Practice location:
  • Phone: 330-492-9200
  • Fax: 330-492-5454
Mailing address:
  • Phone: 330-492-9200
  • Fax: 330-492-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4547
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number4547
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: