Healthcare Provider Details

I. General information

NPI: 1811035967
Provider Name (Legal Business Name): MARTHA S RUBENSTEIN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 E MAIN ST STE 210A
KINGSPORT TN
37660-4257
US

IV. Provider business mailing address

108 E MAIN ST STE 210A
KINGSPORT TN
37660-4257
US

V. Phone/Fax

Practice location:
  • Phone: 423-392-6898
  • Fax: 423-392-6900
Mailing address:
  • Phone: 423-392-6898
  • Fax: 423-392-6900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP1844
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberP1844
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberP1844
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberP1844
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP1844
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: