Provider Demographics
NPI:1689976854
Name:MARTIN, CHRISTIAN ATLAS (MAT, PHD, BCBA)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:ATLAS
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MAT, PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 N LAKE POINTE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-4335
Mailing Address - Country:US
Mailing Address - Phone:803-582-9003
Mailing Address - Fax:803-736-6137
Practice Address - Street 1:82 N LAKE POINTE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-4335
Practice Address - Country:US
Practice Address - Phone:803-582-9003
Practice Address - Fax:803-736-6137
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-10-7427103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCWP8953Medicaid