Healthcare Provider Details

I. General information

NPI: 1750424537
Provider Name (Legal Business Name): MARTHA L HAMILTON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W MAIN ST
THIBODAUX LA
70301-5216
US

IV. Provider business mailing address

PO BOX 416
NORCO LA
70079-0416
US

V. Phone/Fax

Practice location:
  • Phone: 985-447-6214
  • Fax:
Mailing address:
  • Phone: 504-487-7719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number787
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number787
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number787
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: