Healthcare Provider Details

I. General information

NPI: 1144290867
Provider Name (Legal Business Name): MARTHA M KLACZAK LMHC, LADCI, CADACII
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 LITTLEVILLE RD
HUNTINGTON MA
01050-9761
US

IV. Provider business mailing address

PO BOX 10415 230 SOUTHAMPTON RD
HOLYOKE MA
01041-2015
US

V. Phone/Fax

Practice location:
  • Phone: 413-667-0142
  • Fax: 413-667-0145
Mailing address:
  • Phone: 413-534-5860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1147
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: