Basic Information
Provider Information
NPI: 1003295122
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DEHAHN
FirstName: MARTHA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 42 EDELCY DR
Address2:  
City: BELCHERTOWN
State: MA
PostalCode: 010079308
CountryCode: US
TelephoneNumber: 4132504706
FaxNumber:  
Practice Location
Address1: 45 ROUND HILL RD
Address2:  
City: NORTHAMPTON
State: MA
PostalCode: 010602123
CountryCode: US
TelephoneNumber: 4135877387
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/21/2015
LastUpdateDate: 05/21/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
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IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
222Q00000X  Y Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist 

No ID Information.


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