Basic Information
| Provider Information | |||||||||
| NPI: | 1750721452 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CATHERINE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | IMFT-S, BCBA, COBA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | MOLLY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22001 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441184897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163208450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22001 FAIRMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441184819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2169322800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2013 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | COBA.00418 | OH | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106H00000X | M1300014 | OH | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | F.1900094-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.