Provider Demographics
NPI:1386189314
Name:CHARLES R. MARTIN, PH.D., LLC
Entity Type:Organization
Organization Name:CHARLES R. MARTIN, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:352-375-7756
Mailing Address - Street 1:2631 NW 41ST ST
Mailing Address - Street 2:E-6
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-7470
Mailing Address - Country:US
Mailing Address - Phone:352-375-7756
Mailing Address - Fax:
Practice Address - Street 1:2631 NW 41ST ST
Practice Address - Street 2:E-6
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-7470
Practice Address - Country:US
Practice Address - Phone:352-375-7756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5214103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty