Provider Demographics
NPI:1316505969
Name:DI MARTINO, MICHAEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DI MARTINO
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4053 OLD 31 S
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-9691
Mailing Address - Country:US
Mailing Address - Phone:650-387-3927
Mailing Address - Fax:
Practice Address - Street 1:4053 OLD 31 S
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-9691
Practice Address - Country:US
Practice Address - Phone:650-387-3927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1373103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical