=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023508702
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNE MARTINEAU LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2018
-----------------------------------------------------
Last Update Date | 05/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 SPRINGFIELD ST APT 323
-----------------------------------------------------
City | CHICOPEE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01013-2665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-231-2025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 SPRINGFIELD ST APT 323
-----------------------------------------------------
City | CHICOPEE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01013-2665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1027034
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------