Basic Information
| Provider Information | |||||||||
| NPI: | 1821309576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MARY ELLEN | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6625 COUNTRY ESTATES LN | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809083001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056042512 | ||||||||
| FaxNumber: | 5053425414 | ||||||||
| Practice Location | |||||||||
| Address1: | 1218 GRIEGOS RD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871073752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053458471 | ||||||||
| FaxNumber: | 5053425414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2010 | ||||||||
| LastUpdateDate: | 10/16/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106H00000X | MFT.0001249 | CO | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.