Provider Demographics
NPI:1316795545
Name:MARTIN, MICHAEL L (REVEREND)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:M
Credentials:REVEREND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 NEWPORT RD
Mailing Address - Street 2:
Mailing Address - City:MANHEIM
Mailing Address - State:PA
Mailing Address - Zip Code:17545-9350
Mailing Address - Country:US
Mailing Address - Phone:717-824-5965
Mailing Address - Fax:
Practice Address - Street 1:1340 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:MANHEIM
Practice Address - State:PA
Practice Address - Zip Code:17545-9350
Practice Address - Country:US
Practice Address - Phone:717-824-5965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
PA101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)