Healthcare Provider Details

I. General information

NPI: 1659084846
Provider Name (Legal Business Name): HAVEN MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date: 05/14/2026
Reactivation Date: 07/14/2026

III. Provider practice location address

4962 WESTMORELAND CT
RIVERSIDE OH
45431-1135
US

IV. Provider business mailing address

4962 WESTMORELAND CT
RIVERSIDE OH
45431-1135
US

V. Phone/Fax

Practice location:
  • Phone: 937-559-4760
  • Fax:
Mailing address:
  • Phone: 937-559-4760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.2608011
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: