Provider Demographics
NPI:1124569793
Name:MARTIN, DARYL CHEYENNE JR
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:CHEYENNE
Last Name:MARTIN
Suffix:JR
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 1:750 FRANKLIN GATEWAYSE
Mailing Address - Street 2:14-H
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067
Mailing Address - Country:US
Mailing Address - Phone:843-217-3055
Mailing Address - Fax:
Practice Address - Street 1:260 PEACHTREE ST NW
Practice Address - Street 2:SUITE 2200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-1202
Practice Address - Country:US
Practice Address - Phone:843-217-3055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician