Basic Information
| Provider Information | |||||||||
| NPI: | 1073287280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW STE 110 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 SILVER LAKE RD NW STE 110 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2021 | ||||||||
| LastUpdateDate: | 08/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.