=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124265053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN ANDREW MARTIN PH.D., LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2009
-----------------------------------------------------
Last Update Date | 01/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 S WALDRON RD STE 200
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-2590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-478-7048
-----------------------------------------------------
Fax | 479-452-2958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 S WALDRON RD STE 200
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-2590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-478-7048
-----------------------------------------------------
Fax | 479-452-2958
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | P00610054
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 18091
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------