Basic Information
| Provider Information | |||||||||
| NPI: | 1225789779 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37 FRIAR TUCK WAY | ||||||||
| Address2: | |||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128666165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182386028 | ||||||||
| FaxNumber: | 5183481279 | ||||||||
| Practice Location | |||||||||
| Address1: | 37 FRIAR TUCK WAY | ||||||||
| Address2: | |||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128666165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182386028 | ||||||||
| FaxNumber: | 5183481279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2022 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 024653 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.