Provider Demographics
NPI:1598131187
Name:MARTIN, THOMAS RAY
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RAY
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 1:770 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1187
Mailing Address - Country:US
Mailing Address - Phone:276-223-3200
Mailing Address - Fax:276-223-0617
Practice Address - Street 1:416 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-3318
Practice Address - Country:US
Practice Address - Phone:276-783-8185
Practice Address - Fax:276-223-0617
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006249101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional