Provider Demographics
NPI:1003878323
Name:MARTIN, BARBARA T (PHD)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:T
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BARBARA
Other - Middle Name:JANE
Other - Last Name:TAVERNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:1210 1ST ST W
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-1147
Practice Address - Country:US
Practice Address - Phone:651-438-1800
Practice Address - Fax:651-438-1894
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2383103T00000X
WI1339057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R51677Medicare UPIN