Provider Demographics
NPI:1548380686
Name:MARTIN, PAUL L JR (PHD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:L
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 N PONCE DE LEON BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-2650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:904-315-7015
Practice Address - Street 1:2200 N PONCE DE LEON BLVD STE 3
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2650
Practice Address - Country:US
Practice Address - Phone:904-829-9859
Practice Address - Fax:904-315-7015
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3148103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist