Provider Demographics
NPI:1124265053
Name:MARTIN, RYAN ANDREW (PHD, LPC)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:ANDREW
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S WALDRON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2590
Mailing Address - Country:US
Mailing Address - Phone:479-478-7048
Mailing Address - Fax:479-452-2958
Practice Address - Street 1:1401 S WALDRON RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2590
Practice Address - Country:US
Practice Address - Phone:479-478-7048
Practice Address - Fax:479-452-2958
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP00610054101YP2500X
TX18091101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional