Provider Demographics
NPI:1750339024
Name:MARTIN, HENRY GREGG (PHD)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:GREGG
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N WABASH AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-662-6035
Mailing Address - Fax:765-662-9102
Practice Address - Street 1:330 N WABASH AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2600
Practice Address - Country:US
Practice Address - Phone:765-662-6035
Practice Address - Fax:765-662-9102
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010243103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100143810AMedicaid
INS69974Medicare UPIN
IN100143810AMedicaid