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General NPI Number Information
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NPI Number | 1578921623
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Entity Type | Organization
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Legal Business Name | MARY KATHLEEN MARTIN NURSE PRACTITIONER IN PSYCHIATRY, PLLC
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Dates
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Enumeration Date | 02/04/2016
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Last Update Date | 02/04/2016
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Provider Practice Location Address
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Address Line | 21 W 2ND ST SUITE 11
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City | RIVERHEAD
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State | NY
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Zip | 11901-2752
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Country | US
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Telephone | 631-624-7839
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Fax | 631-865-5857
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Provider Business Mailing Address
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Address Line | 375 W MILL RD
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City | MATTITUCK
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State | NY
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Zip | 11952-2079
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Country | US
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Telephone | 631-766-3210
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Fax | 631-865-5857
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Authorized Official
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Title or Position | OWNER
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Name | MARY MARTIN
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Credential | NP
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Telephone | 631-766-3210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP0016X
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Taxonomy Name | Prescribing (Medical) Psychologist
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License Number | 401909
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License Number State | NY
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