Provider Demographics
NPI:1912063447
Name:MARTIN, GARY ROY (MSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 STAGE ROAD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VT
Mailing Address - Zip Code:05477
Mailing Address - Country:US
Mailing Address - Phone:802-434-3745
Mailing Address - Fax:802-434-3804
Practice Address - Street 1:1 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4422
Practice Address - Country:US
Practice Address - Phone:802-862-1511
Practice Address - Fax:802-862-7059
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT103TF0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT062-5119OtherBLUE CROSS BLUE SHIELD
VT0005119Medicaid