Provider Demographics
NPI:1932605565
Name:MARTIN, EDWINA LATASHA (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWINA
Middle Name:LATASHA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:EDWINA
Other - Middle Name:LATASHA
Other - Last Name:REECE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PSC 80 BOX 20501
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0090
Mailing Address - Country:US
Mailing Address - Phone:707-580-0105
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5142
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368-5142
Practice Address - Country:US
Practice Address - Phone:315-634-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical