Provider Demographics
NPI:1770793473
Name:MARTIN, GLEN A (PHD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 E FRANKLIN ST
Mailing Address - Street 2:SUITE 800-F FRANKLIN SQUARE
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-5861
Mailing Address - Country:US
Mailing Address - Phone:919-357-6403
Mailing Address - Fax:
Practice Address - Street 1:1829 E FRANKLIN ST
Practice Address - Street 2:SUITE 800-F FRANKLIN SQUARE
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-5861
Practice Address - Country:US
Practice Address - Phone:919-357-6403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1159103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling