Provider Demographics
NPI:1568956241
Name:MART, ERIC GAYLIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:GAYLIN
Last Name:MART
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 1:230 LAFAYETTE RD STE 7
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-5429
Mailing Address - Country:US
Mailing Address - Phone:603-373-8801
Mailing Address - Fax:
Practice Address - Street 1:230 LAFAYETTE RD STE 7
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5429
Practice Address - Country:US
Practice Address - Phone:603-373-8801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8194103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic