Provider Demographics
NPI:1164590923
Name:MARTIN, ANDREW LEE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:LEE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CHARLTON ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-5231
Mailing Address - Country:US
Mailing Address - Phone:609-454-3214
Mailing Address - Fax:609-250-7108
Practice Address - Street 1:9 CHARLTON ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540
Practice Address - Country:US
Practice Address - Phone:609-454-3214
Practice Address - Fax:609-250-7108
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03841103T00000X
OH6742103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405146700Medicaid
DC77260044OtherBCBS
MD64161101OtherBCBS