Provider Demographics
NPI:1174027361
Name:MARTIN, DEADRA MONIQUE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEADRA
Middle Name:MONIQUE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8310 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-3124
Mailing Address - Country:US
Mailing Address - Phone:443-500-4887
Mailing Address - Fax:
Practice Address - Street 1:8310 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-3124
Practice Address - Country:US
Practice Address - Phone:443-500-4887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2022-09-16
Deactivation Date:2018-03-22
Deactivation Code:
Reactivation Date:2022-09-16
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health