Provider Demographics
NPI:1235476086
Name:MARTIN, TIMOTHY JOHN
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOHN
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 1:1405 SE 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4406
Mailing Address - Country:US
Mailing Address - Phone:816-588-5461
Mailing Address - Fax:
Practice Address - Street 1:8915 SW CENTER STREET
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-726-3691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health