Basic Information
| Provider Information | |||||||||
| NPI: | 1114463643 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRICE | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | BENTON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 STANFORD RD | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217424517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016601662 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1459 POTOMAC AVE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217423315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405134551 | ||||||||
| FaxNumber: | 4108485629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2017 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LC7553 | MD | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 306804800 | 05 | MD | MEDICAID |