Provider Demographics
NPI:1114463643
Name:PRICE, MARTIN BENTON (MS, LCPC)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:BENTON
Last Name:PRICE
Suffix:
Gender:M
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 STANFORD RD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-4517
Mailing Address - Country:US
Mailing Address - Phone:301-660-1662
Mailing Address - Fax:
Practice Address - Street 1:1459 POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-3315
Practice Address - Country:US
Practice Address - Phone:240-513-4551
Practice Address - Fax:410-848-5629
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-08
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7553101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD306804800Medicaid