Provider Demographics
NPI:1295979771
Name:MARTIN, GREGORY ALBERT (MA)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALBERT
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MA
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 2201
Mailing Address - Street 2:OPEN SKY WILDERNESS THERAPY
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-2201
Mailing Address - Country:US
Mailing Address - Phone:970-382-8181
Mailing Address - Fax:970-382-9494
Practice Address - Street 1:466 SOUTH SKYLANE DRIVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303
Practice Address - Country:US
Practice Address - Phone:970-382-8181
Practice Address - Fax:970-382-9494
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
UT5960584-60101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional