Healthcare Provider Details

I. General information

NPI: 1740281138
Provider Name (Legal Business Name): GREGORY M MARTINO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 MC CRACKEN RUN ROAD
DUBOIS PA
15801-3634
US

IV. Provider business mailing address

214 MC CRACKEN RUN ROAD
DUBOIS PA
15801-3634
US

V. Phone/Fax

Practice location:
  • Phone: 814-371-2577
  • Fax: 814-371-2577
Mailing address:
  • Phone: 814-371-2577
  • Fax: 814-371-2577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS008503L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: