MEDICARE: NANCY J. MARTINO M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	1367	MN

General Provider Information

NPI Number	:	1407170673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY J. MARTINO M.A.

Provider Business Mailing Address
First Line	:	34 WATER ST
Second Line	:	SUITE C
City	:	EXCELSIOR
State	:	MN
Zip	:	55331-1846
Country	:	US
Telephone Number	:	952-474-1912
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 WATER ST
Second Line	:	SUITE C
City	:	EXCELSIOR
State	:	MN
Zip	:	55331-1846
Country	:	US
Telephone Number	:	952-474-1912
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2010
Last Update Date	:	03/17/2010

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