Provider Demographics
NPI:1093078677
Name:MARTIN, DAVID MICHAEL (MA, MATS, LPC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MA, MATS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 SE TIBBETTS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2043
Mailing Address - Country:US
Mailing Address - Phone:503-880-1508
Mailing Address - Fax:
Practice Address - Street 1:1210 SE OAK ST
Practice Address - Street 2:SUITE 3
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1427
Practice Address - Country:US
Practice Address - Phone:503-880-1508
Practice Address - Fax:971-229-0928
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3306101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500670213Medicaid