Healthcare Provider Details

I. General information

NPI: 1417331380
Provider Name (Legal Business Name): MARYANN MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3907 S 186TH LN
GOODYEAR AZ
85338-7641
US

IV. Provider business mailing address

1755 N PEBBLE CREEK PKWY
GOODYEAR AZ
85395-2532
US

V. Phone/Fax

Practice location:
  • Phone: 623-556-7459
  • Fax:
Mailing address:
  • Phone: 623-556-7459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-22218
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: