Provider Demographics
NPI:1306054986
Name:MARTIN, DAVID EVAN (MA LPC, LPCC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:EVAN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MA LPC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 TERRACINA BLVD
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5643
Mailing Address - Country:US
Mailing Address - Phone:405-761-5493
Mailing Address - Fax:
Practice Address - Street 1:1330 E COOLEY DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3905
Practice Address - Country:US
Practice Address - Phone:405-761-5493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4882101YP2500X
CA3808101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALPCC3808OtherBOARD OF BEHAVIORAL SCIENCES