Provider Demographics
NPI:1154876563
Name:PRICE, MARTY DEWAYNE (PHD, BCBA)
Entity type:Individual
Prefix:MR
First Name:MARTY
Middle Name:DEWAYNE
Last Name:PRICE
Suffix:
Gender:M
Credentials:PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:902 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2210
Mailing Address - Country:US
Mailing Address - Phone:618-937-6483
Mailing Address - Fax:618-937-1440
Practice Address - Street 1:402 E PLAZA DR STE 4
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-2091
Practice Address - Country:US
Practice Address - Phone:618-319-6060
Practice Address - Fax:618-681-6824
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-15-18488103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst