=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124923297
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. GEFFREY SHAWN MARTIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2026
-----------------------------------------------------
Last Update Date | 10/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 SARNO RD STE 1
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32935-3989
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-622-4066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 ROSTOCK CIR NW
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907-7879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-307-2811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 29843
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------