Provider Demographics
NPI:1053838581
Name:MARTIN, BREANN NICOLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BREANN
Middle Name:NICOLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-1679
Mailing Address - Country:US
Mailing Address - Phone:714-767-2949
Mailing Address - Fax:
Practice Address - Street 1:1400 EXECUTIVE PKWY STE 260
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7121
Practice Address - Country:US
Practice Address - Phone:458-215-5397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2730103T00000X, 103TF0200X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103T00000XBehavioral Health & Social Service ProvidersPsychologist