Healthcare Provider Details

I. General information

NPI: 1538684634
Provider Name (Legal Business Name): COLLEEN MARTIN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 VINE ST
CINCINNATI OH
45220-2213
US

IV. Provider business mailing address

4219 FLORAL AVE
CINCINNATI OH
45212-3216
US

V. Phone/Fax

Practice location:
  • Phone: 937-546-1001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP.07722
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: