Healthcare Provider Details

I. General information

NPI: 1780822932
Provider Name (Legal Business Name): MELISSA MARTIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 MAIN ST
BINGHAMTON NY
13905-2524
US

IV. Provider business mailing address

303 MAIN ST
BINGHAMTON NY
13905-2524
US

V. Phone/Fax

Practice location:
  • Phone: 607-584-4470
  • Fax: 607-584-4480
Mailing address:
  • Phone: 607-584-4470
  • Fax: 607-584-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number072677
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: