Provider Demographics
NPI:1659670206
Name:MARTIN, RENE
Entity Type:Individual
Prefix:
First Name:RENE
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 1:350 POPLAR SPRING HOSPITAL
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23860
Mailing Address - Country:US
Mailing Address - Phone:804-733-6874
Mailing Address - Fax:804-861-5625
Practice Address - Street 1:350 POPLAR SPRING HOSPITAL
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23860
Practice Address - Country:US
Practice Address - Phone:804-733-6874
Practice Address - Fax:804-861-5625
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040031471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical