Provider Demographics
NPI:1790941557
Name:MARTIN, CHARLES ROBERT (LMFT LMHC NCC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ROBERT
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LMFT LMHC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 CHERRY ST
Mailing Address - Street 2:ST MARYS MINISTRY CENTER
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1807
Mailing Address - Country:US
Mailing Address - Phone:812-425-1577
Mailing Address - Fax:812-426-1416
Practice Address - Street 1:613 CHERRY ST
Practice Address - Street 2:ST MARYS MINISTRY CENTER
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1807
Practice Address - Country:US
Practice Address - Phone:812-425-1577
Practice Address - Fax:812-426-1416
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000879A101YM0800X
IN35000349A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health