Provider Demographics
NPI:1932793775
Name:MARTIN, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
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 1:11893 CATALPA ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-2314
Mailing Address - Country:US
Mailing Address - Phone:504-210-7789
Mailing Address - Fax:
Practice Address - Street 1:11893 CATALPA ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-2314
Practice Address - Country:US
Practice Address - Phone:504-210-7789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty