Provider Demographics
NPI:1881469021
Name:MARTIN, DEREK THOMAS
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:THOMAS
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 1:8609 2ND AVE STE 506B
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3362
Mailing Address - Country:US
Mailing Address - Phone:240-298-3514
Mailing Address - Fax:
Practice Address - Street 1:8609 2ND AVE STE 506B
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3362
Practice Address - Country:US
Practice Address - Phone:240-298-3514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-23-290851106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician