Basic Information
| Provider Information | |||||||||
| NPI: | 1548552292 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY MARTIN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARY MARTIN COUNSELING SERVICES LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1388 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187040388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702888881 | ||||||||
| FaxNumber: | 5702888065 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 3RD AVE | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187045816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704172830 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2011 | ||||||||
| LastUpdateDate: | 03/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | LCSW | ||||||||
| AuthorizedOfficialTelephone: | 5704172830 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | CW014765 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.