Provider Demographics
NPI:1083081020
Name:MARTIN, STACY (PHD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4890 MAJESTIC DR
Mailing Address - Street 2:
Mailing Address - City:COOPERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18036-8722
Mailing Address - Country:US
Mailing Address - Phone:610-295-7834
Mailing Address - Fax:
Practice Address - Street 1:6666 PASSER RD STE 2
Practice Address - Street 2:
Practice Address - City:COOPERSBURG
Practice Address - State:PA
Practice Address - Zip Code:18036-1258
Practice Address - Country:US
Practice Address - Phone:484-935-3434
Practice Address - Fax:484-544-3901
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017666103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist