Provider Demographics
NPI:1578337424
Name:MARTIN, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4596 SE PARSONS GREEN CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9077
Mailing Address - Country:US
Mailing Address - Phone:360-979-9725
Mailing Address - Fax:
Practice Address - Street 1:4596 SE PARSONS GREEN CT
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98367-9077
Practice Address - Country:US
Practice Address - Phone:360-979-9725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician