1427385244 NPI number — MR. CORY JON MARTIN LCSW, MPA

Table of content: LARA M STEPLEMAN PHD (NPI 1497866958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427385244 NPI number — MR. CORY JON MARTIN LCSW, MPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
CORY
Provider Middle Name:
JON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW, MPA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427385244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
913 NW GARDEN VALLEY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97471-6523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-242-0460
Provider Business Mailing Address Fax Number:
541-465-6602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 E 7TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-2773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-242-0460
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  7238604-3502 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 7238604-3501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7238604-3502 . This is a "STATE OF UTAH DEPARTMENT OF PROFESSIONAL LICENSING" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 7238604-3501 . This is a "STATE OF UTAH - DEPARTMENT OF COMMERCE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com