Provider Demographics
NPI:1629481874
Name:MARTIN, MICHELLE (EDS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EDS
Mailing Address - Street 1:25901 EMERY RD STE 112
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-6213
Mailing Address - Country:US
Mailing Address - Phone:216-765-4470
Mailing Address - Fax:216-765-4471
Practice Address - Street 1:25901 EMERY RD STE 112
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-6213
Practice Address - Country:US
Practice Address - Phone:216-765-4470
Practice Address - Fax:216-765-4471
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP374103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool