Provider Demographics
NPI:1932338647
Name:MARTIN, ERIC DOUGLAS (CCJP)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:DOUGLAS
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CCJP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7209J E WT HARRIS BLVD # 199
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-1008
Mailing Address - Country:US
Mailing Address - Phone:704-649-3153
Mailing Address - Fax:
Practice Address - Street 1:7209J E WT HARRIS BLVD # 199
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-1008
Practice Address - Country:US
Practice Address - Phone:704-649-3153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC72101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)