Healthcare Provider Details

I. General information

NPI: 1174703763
Provider Name (Legal Business Name): MARTIN JAMES LYTHGOE CADC III, NCAC II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 08/14/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 MARIAN AVENUE
CENTRAL POINT OR
97502-7009
US

IV. Provider business mailing address

286 MARIAN AVENUE
CENTRAL POINT OR
97502-7009
US

V. Phone/Fax

Practice location:
  • Phone: 541-727-7088
  • Fax:
Mailing address:
  • Phone: 805-377-7116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24-R-27
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA3553789
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: