Provider Demographics
NPI:1861674442
Name:MARTIN, WAYNE FREDERICK (PHD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:FREDERICK
Last Name:MARTIN
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 1:7400 MERTON MINTER ST
Mailing Address - Street 2:PSYCHOLOGY SERVICE
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4404
Mailing Address - Country:US
Mailing Address - Phone:210-884-4643
Mailing Address - Fax:
Practice Address - Street 1:7400 MERTON MINTER ST
Practice Address - Street 2:PSYCHOLOGY SERVICE
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-884-4643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16799103T00000X, 103TF0000X, 103TH0004X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy