Provider Demographics
NPI:1427385244
Name:MARTIN, CORY JON (LCSW, MPA)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:JON
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCSW, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 NW GARDEN VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6523
Mailing Address - Country:US
Mailing Address - Phone:541-242-0460
Mailing Address - Fax:541-465-6602
Practice Address - Street 1:211 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2773
Practice Address - Country:US
Practice Address - Phone:541-242-0460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7238604-3502104100000X
UT7238604-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7238604-3502OtherSTATE OF UTAH DEPARTMENT OF PROFESSIONAL LICENSING
UT7238604-3501OtherSTATE OF UTAH - DEPARTMENT OF COMMERCE