Provider Demographics
NPI:1730339748
Name:MARTIN, TANYA LYNNETTE (PSYD, LLP)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:LYNNETTE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSYD, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18181 OAKWOOD BLVD STE 311
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-5031
Mailing Address - Country:US
Mailing Address - Phone:313-271-8170
Mailing Address - Fax:313-271-8353
Practice Address - Street 1:18181 OAKWOOD BLVD STE 311
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5031
Practice Address - Country:US
Practice Address - Phone:313-271-8170
Practice Address - Fax:313-271-8353
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008325103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301008325OtherLICENSE NUMBER