Provider Demographics
NPI:1497058267
Name:DAGUIN MARTYR, GHISLAINE
Entity Type:Individual
Prefix:
First Name:GHISLAINE
Middle Name:
Last Name:DAGUIN MARTYR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7861 THE LAKES PT
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4604
Mailing Address - Country:US
Mailing Address - Phone:813-846-7254
Mailing Address - Fax:
Practice Address - Street 1:7861 THE LAKES PT
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-4604
Practice Address - Country:US
Practice Address - Phone:813-846-7254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-23-69323103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst