Provider Demographics
NPI:1588742753
Name:MARTIN, PHYLLIS (PHD)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 COMMERCIAL ST SE
Mailing Address - Street 2:# 101-258
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4981
Mailing Address - Country:US
Mailing Address - Phone:503-896-0297
Mailing Address - Fax:503-470-1108
Practice Address - Street 1:1301 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:MARSHALLTOWN
Practice Address - State:IA
Practice Address - Zip Code:50158-5484
Practice Address - Country:US
Practice Address - Phone:641-753-4518
Practice Address - Fax:641-753-4203
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3028103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP67781Medicare UPIN