Healthcare Provider Details

I. General information

NPI: 1902105448
Provider Name (Legal Business Name): MR. MICHAEL L. MARTINI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2011
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 GEYSER RD
BALLSTON SPA NY
12020-3022
US

IV. Provider business mailing address

133 DROMS RD
SCOTIA NY
12302-9739
US

V. Phone/Fax

Practice location:
  • Phone: 518-885-6884
  • Fax:
Mailing address:
  • Phone: 518-860-9421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: