Basic Information
Provider Information
NPI: 1033556782
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MARTIN
FirstName: TERRY
MiddleName: ALLEN
NamePrefix: MR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 466 CRESCENT ST
Address2: 216
City: OAKLAND
State: CA
PostalCode: 946102662
CountryCode: US
TelephoneNumber: 4152353818
FaxNumber:  
Practice Location
Address1: 1931 CENTER ST
Address2:  
City: BERKELEY
State: CA
PostalCode: 947041105
CountryCode: US
TelephoneNumber: 5106669552
FaxNumber: 5106660987
Other Information
ProviderEnumerationDate: 06/03/2013
LastUpdateDate: 06/03/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X  Y Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)

No ID Information.


Home