Basic Information
| Provider Information | |||||||||
| NPI: | 1093192775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 3070 | ||||||||
| Address2: | 3500 DEPAUW BOULEVARD | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Practice Location | |||||||||
| Address1: | 4422 E STATE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468156917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604719263 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2015 | ||||||||
| LastUpdateDate: | 12/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-15-18339 | 01 | BCBA BOARD CERTIFICATION | OTHER |