Provider Demographics
NPI:1821113622
Name:MARTIN, RICKY RAY
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:RAY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6196
Mailing Address - Street 2:601 GREGG AVE
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502
Mailing Address - Country:US
Mailing Address - Phone:843-665-9349
Mailing Address - Fax:843-669-6122
Practice Address - Street 1:601 GREGG AVE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29502
Practice Address - Country:US
Practice Address - Phone:843-665-9349
Practice Address - Fax:843-669-6122
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCICADC15584101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)