Provider Demographics
NPI:1588633754
Name:BURESH, MARTIN CHARLES (PHD)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:CHARLES
Last Name:BURESH
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 1:602 PINE STREET
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:75501-5517
Mailing Address - Country:US
Mailing Address - Phone:903-792-1608
Mailing Address - Fax:903-792-0899
Practice Address - Street 1:602 PINE STREET
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:75501-5517
Practice Address - Country:US
Practice Address - Phone:903-792-1608
Practice Address - Fax:903-792-0899
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP8811023101YP2500X
TX8751101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional