Provider Demographics
NPI:1457491060
Name:MARTIN, RANDALL DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DAVID
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 IRVINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DOBBS FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:10522-2610
Mailing Address - Country:US
Mailing Address - Phone:914-479-0934
Mailing Address - Fax:
Practice Address - Street 1:369 ASHFORD AVE
Practice Address - Street 2:
Practice Address - City:DOBBS FERRY
Practice Address - State:NY
Practice Address - Zip Code:10522-2626
Practice Address - Country:US
Practice Address - Phone:914-907-2795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011698103T00000X, 103TC1900X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent