Provider Demographics
NPI:1487862074
Name:MARTIN, GLORIA HOWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:HOWARD
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 EASTOVER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-6720
Mailing Address - Country:US
Mailing Address - Phone:601-366-7876
Mailing Address - Fax:
Practice Address - Street 1:2508 LAKELAND DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9502
Practice Address - Country:US
Practice Address - Phone:601-664-0455
Practice Address - Fax:601-664-1675
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC12591041C0700X
MST0006106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist