Provider Demographics
NPI:1073866117
Name:MARTIN, CHARLES STEVEN II (BA, QMHP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:STEVEN
Last Name:MARTIN
Suffix:II
Gender:M
Credentials:BA, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PINERIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-9124
Mailing Address - Country:US
Mailing Address - Phone:434-962-6039
Mailing Address - Fax:
Practice Address - Street 1:200 PINERIDGE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-9124
Practice Address - Country:US
Practice Address - Phone:434-962-6039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist