Provider Demographics
NPI:1245843838
Name:MARTIN, DANIEL PHILLIP
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:PHILLIP
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 1:91 W COLT SQUARE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2846
Mailing Address - Country:US
Mailing Address - Phone:479-629-5519
Mailing Address - Fax:479-316-2904
Practice Address - Street 1:91 W COLT SQUARE DR STE 4
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2846
Practice Address - Country:US
Practice Address - Phone:479-629-5519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10158-C1041C0700X
AR10158M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker