Provider Demographics
NPI:1134615750
Name:BURNHAM, MARTIN JOSEPH
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:JOSEPH
Last Name:BURNHAM
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 1:4210 N CHARLES ST APT 5
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-1041
Mailing Address - Country:US
Mailing Address - Phone:443-438-6775
Mailing Address - Fax:
Practice Address - Street 1:5408 ROLAND AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21210-1900
Practice Address - Country:US
Practice Address - Phone:410-864-3629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8717101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional