Provider Demographics
NPI:1841894813
Name:DANNER, MARTIN DEAN
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:DEAN
Last Name:DANNER
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 1:260 STILL HOLLOW CRK
Mailing Address - Street 2:
Mailing Address - City:BUDA
Mailing Address - State:TX
Mailing Address - Zip Code:78610-3068
Mailing Address - Country:US
Mailing Address - Phone:817-372-0335
Mailing Address - Fax:
Practice Address - Street 1:112 CIMARRON PARK LOOP STE B
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-2850
Practice Address - Country:US
Practice Address - Phone:817-372-0335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77951101YP2500X
TX203032106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX77951OtherTEXAS BEHAVIORAL HEALTH EXECUTIVE COUNCIL
TX203032OtherTEXAS BEHAVIORAL HEALTH EXECUTIVE COUNCIL