Provider Demographics
NPI:1245244714
Name:MARTIN, LINDA E (PHD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:E
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 NERA AVE
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952
Mailing Address - Country:US
Mailing Address - Phone:321-433-1466
Mailing Address - Fax:321-433-1467
Practice Address - Street 1:630 BREVARD AVE
Practice Address - Street 2:STE 100
Practice Address - City:COCA
Practice Address - State:FL
Practice Address - Zip Code:32922
Practice Address - Country:US
Practice Address - Phone:321-433-1466
Practice Address - Fax:321-433-1467
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3875103T00000X
FLMT1001106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
73223Medicare ID - Type Unspecified