Provider Demographics
NPI:1679973812
Name:MARTIN, GRAHAM (MA)
Entity Type:Individual
Prefix:MR
First Name:GRAHAM
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 WESTFIELD CT
Mailing Address - Street 2:320
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5073
Mailing Address - Country:US
Mailing Address - Phone:214-662-5036
Mailing Address - Fax:
Practice Address - Street 1:135 WESTFIELD CT
Practice Address - Street 2:320
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5073
Practice Address - Country:US
Practice Address - Phone:214-662-5036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health