Provider Demographics
NPI:1912230178
Name:MARTIN, MOZELLE BARR (PHD)
Entity Type:Individual
Prefix:MS
First Name:MOZELLE
Middle Name:BARR
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 S. 5TH AVE.
Mailing Address - Street 2:#1427
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546
Mailing Address - Country:US
Mailing Address - Phone:928-985-5050
Mailing Address - Fax:602-733-6538
Practice Address - Street 1:3734 W. VISTA AVE.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051
Practice Address - Country:US
Practice Address - Phone:623-850-8198
Practice Address - Fax:888-306-2742
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2020-09-25
Deactivation Date:2018-01-24
Deactivation Code:
Reactivation Date:2020-09-25
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 103K00000X
AZP0214763101YP1600X
AZ103K00000X, 101YP1600X
ZZ00012175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No175L00000XOther Service ProvidersHomeopath