Provider Demographics
NPI:1932187986
Name:MARTIN, SANFORD PAUL JR (EDD)
Entity type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:PAUL
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 BATTLEFIELD BLVD N
Mailing Address - Street 2:SUITE 115
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4516
Mailing Address - Country:US
Mailing Address - Phone:757-312-8002
Mailing Address - Fax:757-312-9299
Practice Address - Street 1:1417 BATTLEFIELD BLVD N
Practice Address - Street 2:SUITE 115
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4516
Practice Address - Country:US
Practice Address - Phone:757-312-8002
Practice Address - Fax:757-312-9299
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001939101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701001939OtherLPC LICENSE
VA54-05157Medicaid