Healthcare Provider Details

I. General information

NPI: 1659431377
Provider Name (Legal Business Name): ROBERT G. MARTIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 A COURT AVE.
HAMLIN WV
25523-1434
US

IV. Provider business mailing address

8150 A COURT AVE.
HAMLIN WV
25523-1434
US

V. Phone/Fax

Practice location:
  • Phone: 304-824-7776
  • Fax: 304-824-7776
Mailing address:
  • Phone: 304-824-7776
  • Fax: 304-824-7776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number366
License Number StateWV

VIII. Authorized Official

Name: MR. ROBERT G. MARTIN
Title or Position: OWNER
Credential: M.A.
Phone: 304-824-7776