Provider Demographics
NPI:1619742103
Name:MARTIN, PAUL PHILLIP
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:PHILLIP
Last Name:MARTIN
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 1:140 W WEST ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-3739
Mailing Address - Country:US
Mailing Address - Phone:410-752-4454
Mailing Address - Fax:
Practice Address - Street 1:140 W WEST ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-3739
Practice Address - Country:US
Practice Address - Phone:410-752-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC1841101YA0400X
103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)