Provider Demographics
NPI:1700645736
Name:MARTIN PHD, ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:MARTIN PHD
Suffix:
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 1:2537 WARDS MILL RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-8621
Mailing Address - Country:US
Mailing Address - Phone:618-944-0000
Mailing Address - Fax:775-942-1334
Practice Address - Street 1:2537 WARDS MILL RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-8621
Practice Address - Country:US
Practice Address - Phone:618-944-0000
Practice Address - Fax:775-942-1334
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1924103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty