Provider Demographics
NPI:1144233297
Name:MARTIN, STEPHEN KELLY (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:KELLY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 PALUXY DR
Mailing Address - Street 2:SUITE 450
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1629
Mailing Address - Country:US
Mailing Address - Phone:903-258-9938
Mailing Address - Fax:903-534-8104
Practice Address - Street 1:3800 PALUXY DR
Practice Address - Street 2:SUITE 450
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1629
Practice Address - Country:US
Practice Address - Phone:903-258-9938
Practice Address - Fax:903-534-8104
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4740103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00914EMedicare ID - Type Unspecified