Provider Demographics
NPI:1073362307
Name:MARTIN, RONALD TYLER
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:TYLER
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4443 GROVE DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6397
Mailing Address - Country:US
Mailing Address - Phone:678-320-7730
Mailing Address - Fax:
Practice Address - Street 1:4443 GROVE DR NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-6397
Practice Address - Country:US
Practice Address - Phone:678-320-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician