Provider Demographics
NPI:1104037803
Name:MARTINE, MARVIN R (LISAC)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:R
Last Name:MARTINE
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:SANDERS
Mailing Address - State:AZ
Mailing Address - Zip Code:86512-1086
Mailing Address - Country:US
Mailing Address - Phone:928-688-3475
Mailing Address - Fax:928-688-3478
Practice Address - Street 1:4 MLS S OF I-40 ON HWY 191, SANDERS
Practice Address - Street 2:
Practice Address - City:SANDERS
Practice Address - State:AZ
Practice Address - Zip Code:86512-1086
Practice Address - Country:US
Practice Address - Phone:928-688-3475
Practice Address - Fax:928-688-3478
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11363101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)