Provider Demographics
NPI:1720591183
Name:MARTIN, RICHARD ALLEN (PHD,MBA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1502
Mailing Address - Country:US
Mailing Address - Phone:641-780-1087
Mailing Address - Fax:
Practice Address - Street 1:1402 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1502
Practice Address - Country:US
Practice Address - Phone:641-204-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00317103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist