MEDICARE: DR. CANDACE LOUISE MARTIN PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	20040983A	IN

General Provider Information

NPI Number	:	1114137080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CANDACE LOUISE MARTIN PSY.D.

Provider Business Mailing Address
First Line	:	6319 CONSTITUTION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1547
Country	:	US
Telephone Number	:	260-432-4346
Fax Number	:	260-432-4860

Provider Business Practice Location Address
First Line	:	6319 CONSTITUTION DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1547
Country	:	US
Telephone Number	:	260-432-4346
Fax Number	:	260-432-4860

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/08/2007

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