Provider Demographics
NPI:1154060416
Name:MARTIN, DERRICK ADAM
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:ADAM
Last Name:MARTIN
Suffix:
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 1:1501 W TAPP RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3459
Mailing Address - Country:US
Mailing Address - Phone:812-330-4460
Mailing Address - Fax:812-330-4461
Practice Address - Street 1:1501 W TAPP RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3459
Practice Address - Country:US
Practice Address - Phone:812-330-4460
Practice Address - Fax:812-330-4461
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-22-218726106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician