Healthcare Provider Details

I. General information

NPI: 1750721452
Provider Name (Legal Business Name): MARY CATHERINE MARTIN IMFT-S, BCBA, COBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOLLY MARTIN

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

IV. Provider business mailing address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4897
US

V. Phone/Fax

Practice location:
  • Phone: 216-932-2800
  • Fax:
Mailing address:
  • Phone: 216-320-8450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberF.1900094-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM1300014
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberCOBA.00418
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: