Basic Information
| Provider Information | |||||||||
| NPI: | 1588707855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | TOM | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4475 DAISY ST | ||||||||
| Address2: | SPACE # 61 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974786681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417267128 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1790 W 11TH AVENUE | ||||||||
| Address2: | SHELTERCARE | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416861262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.