Provider Demographics
NPI:1356059836
Name:MARTIN, EARL WARREN
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:WARREN
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 1:130 APRILS WAY
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-6541
Mailing Address - Country:US
Mailing Address - Phone:215-399-8339
Mailing Address - Fax:
Practice Address - Street 1:130 APRILS WAY
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-6541
Practice Address - Country:US
Practice Address - Phone:215-399-8339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician