Provider Demographics
NPI:1164916805
Name:MARTIN, MARK (CDCA166404)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CDCA166404
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 ARBORETUM CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44067-2340
Mailing Address - Country:US
Mailing Address - Phone:330-348-7808
Mailing Address - Fax:
Practice Address - Street 1:11811 SHAKER BLVD STE 123
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-1927
Practice Address - Country:US
Practice Address - Phone:216-965-6325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-17
Last Update Date:2018-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.166404101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.166404Medicaid