Healthcare Provider Details

I. General information

NPI: 1861674442
Provider Name (Legal Business Name): WAYNE FREDERICK MARTIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 MERTON MINTER ST PSYCHOLOGY SERVICE
SAN ANTONIO TX
78229-4404
US

IV. Provider business mailing address

7400 MERTON MINTER ST PSYCHOLOGY SERVICE
SAN ANTONIO TX
78229-4404
US

V. Phone/Fax

Practice location:
  • Phone: 210-884-4643
  • Fax:
Mailing address:
  • Phone: 210-884-4643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number16799
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number16799
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number16799
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number16799
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: