Provider Demographics
NPI:1922028893
Name:MARTIN, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
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 1:32345 RIVERLAKE RD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:AL
Mailing Address - Zip Code:36574-2793
Mailing Address - Country:US
Mailing Address - Phone:251-988-1437
Mailing Address - Fax:850-416-7348
Practice Address - Street 1:5150 BAYOU BLVD
Practice Address - Street 2:STE 1N
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2158
Practice Address - Country:US
Practice Address - Phone:850-416-7656
Practice Address - Fax:850-416-7348
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker