Provider Demographics
NPI:1649640053
Name:MARTIN, CHARLES BRENT (MS, BCBA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:BRENT
Last Name:MARTIN
Suffix:
Gender:
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 JENKS AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2439
Mailing Address - Country:US
Mailing Address - Phone:850-215-6770
Mailing Address - Fax:850-665-0123
Practice Address - Street 1:1120 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2439
Practice Address - Country:US
Practice Address - Phone:850-215-6770
Practice Address - Fax:850-665-0123
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-10-6993103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017665000Medicaid