Provider Demographics
NPI:1073391991
Name:MARTIN, IRA JAMES III
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:JAMES
Last Name:MARTIN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1667 FARINDALE CV
Mailing Address - Street 2:
Mailing Address - City:NESBIT
Mailing Address - State:MS
Mailing Address - Zip Code:38651-6208
Mailing Address - Country:US
Mailing Address - Phone:662-806-8804
Mailing Address - Fax:
Practice Address - Street 1:1331 UNION AVE STE 1000
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7501
Practice Address - Country:US
Practice Address - Phone:901-459-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6562101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health