Provider Demographics
NPI:1558577395
Name:POE, MARTIN JAMES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JAMES
Last Name:POE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 WASHINGTON AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4238
Mailing Address - Country:US
Mailing Address - Phone:262-763-7249
Mailing Address - Fax:
Practice Address - Street 1:5200 WASHINGTON AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4238
Practice Address - Country:US
Practice Address - Phone:262-763-7249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1302103TC0700X, 103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39083800Medicaid
WI39083800Medicaid