Basic Information
| Provider Information | |||||||||
| NPI: | 1780635805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINO | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7177096529 | ||||||||
| Practice Location | |||||||||
| Address1: | 354 N READING RD | ||||||||
| Address2: | |||||||||
| City: | EPHRATA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175221651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1773811257 | ||||||||
| FaxNumber: | 7177380606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PS006579L | PA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | PS006579L | 01 | PA | STATE LICENSE | OTHER | 11583541 | 01 | CAQH | OTHER | 001502080 | 05 | PA | MEDICAID |