Provider Demographics
NPI:1689793325
Name:AYLESWORTH, MARTIN EUGENE (MS)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:EUGENE
Last Name:AYLESWORTH
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 PAUL REVERE RD
Mailing Address - Street 2:
Mailing Address - City:OIL CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16301-1135
Mailing Address - Country:US
Mailing Address - Phone:814-676-0551
Mailing Address - Fax:
Practice Address - Street 1:67 PAUL REVERE RD
Practice Address - Street 2:
Practice Address - City:OIL CITY
Practice Address - State:PA
Practice Address - Zip Code:16301-1135
Practice Address - Country:US
Practice Address - Phone:814-676-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005733L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist