Provider Demographics
NPI:1407250392
Name:MARTIN, DAVID G (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1853 MADISON ST
Mailing Address - Street 2:UNIT 8
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5299
Mailing Address - Country:US
Mailing Address - Phone:615-613-1869
Mailing Address - Fax:931-919-2191
Practice Address - Street 1:279 CLEAR SKY CT
Practice Address - Street 2:SUITE C
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5946
Practice Address - Country:US
Practice Address - Phone:615-613-1869
Practice Address - Fax:931-919-2191
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-14-9787103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-14-9787OtherBACB CERTIFICATION NUMBER