Healthcare Provider Details

I. General information

NPI: 1215866702
Provider Name (Legal Business Name): TYRONE MARTIN CDCA, PRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 STONERIDGE DR
CIRCLEVILLE OH
43113-8956
US

IV. Provider business mailing address

2065 STONERIDGE DR
CIRCLEVILLE OH
43113-8956
US

V. Phone/Fax

Practice location:
  • Phone: 740-500-1391
  • Fax:
Mailing address:
  • Phone: 740-500-1391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.194854
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.005867
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: