Provider Demographics
NPI:1245394352
Name:MARTIN, GEORGE (LP)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 COUNTY ROAD C E STE 5
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1383
Mailing Address - Country:US
Mailing Address - Phone:651-263-2606
Mailing Address - Fax:
Practice Address - Street 1:127 COUNTY ROAD C E STE 5
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117-1383
Practice Address - Country:US
Practice Address - Phone:651-263-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1095103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist