Healthcare Provider Details

I. General information

NPI: 1790089050
Provider Name (Legal Business Name): MARTHA HUTCHISON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2010
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 AIRPORT RD STE 103
MEDFORD OR
97501
US

IV. Provider business mailing address

503 AIRPORT RD STE 103
MEDFORD OR
97504
US

V. Phone/Fax

Practice location:
  • Phone: 541-816-4415
  • Fax: 541-816-4415
Mailing address:
  • Phone: 541-816-4415
  • Fax: 541-816-4415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL4160
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: