1578921623 NPI number — MARY KATHLEEN MARTIN NURSE PRACTITIONER IN PSYCHIATRY, PLLC

Table of content: (NPI 1578921623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578921623 NPI number — MARY KATHLEEN MARTIN NURSE PRACTITIONER IN PSYCHIATRY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY KATHLEEN MARTIN NURSE PRACTITIONER IN PSYCHIATRY, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578921623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
375 W MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTITUCK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11952-2079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-766-3210
Provider Business Mailing Address Fax Number:
631-865-5857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 W 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
RIVERHEAD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11901-2752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-624-7839
Provider Business Practice Location Address Fax Number:
631-865-5857
Provider Enumeration Date:
02/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
631-766-3210

Provider Taxonomy Codes

  • Taxonomy code: 103TP0016X , with the licence number:  401909 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 13554525 . This is a "CAQH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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