Provider Demographics
NPI:1639611973
Name:MARTIN, DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:MARTIN
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 1:10 MAPLE LEAF FARM RD
Mailing Address - Street 2:
Mailing Address - City:UNDERHILL
Mailing Address - State:VT
Mailing Address - Zip Code:05489-9358
Mailing Address - Country:US
Mailing Address - Phone:609-933-4734
Mailing Address - Fax:
Practice Address - Street 1:10 MAPLE LEAF FARM RD
Practice Address - Street 2:
Practice Address - City:UNDERHILL
Practice Address - State:VT
Practice Address - Zip Code:05489-9358
Practice Address - Country:US
Practice Address - Phone:609-933-4734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048.0134175103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling