Provider Demographics
NPI:1104128446
Name:MARTYN, PATRICK TODD (BA)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:TODD
Last Name:MARTYN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 FORTUNE PKWY
Mailing Address - Street 2:903
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6746
Mailing Address - Country:US
Mailing Address - Phone:904-538-0713
Mailing Address - Fax:904-538-0714
Practice Address - Street 1:10175 FORTUNE PKWY
Practice Address - Street 2:903
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6746
Practice Address - Country:US
Practice Address - Phone:904-538-0713
Practice Address - Fax:904-538-0714
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-10-3974103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst