Provider Demographics
NPI:1770634198
Name:MARTIN, THOMAS O (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:O
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5621 SAVINA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1155
Mailing Address - Country:US
Mailing Address - Phone:937-231-2699
Mailing Address - Fax:
Practice Address - Street 1:5621 SAVINA AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1155
Practice Address - Country:US
Practice Address - Phone:937-231-2699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3011103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic