Provider Demographics
NPI:1083719884
Name:CORREA, MARTHA L (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:L
Last Name:CORREA
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 1:740 W END AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6246
Mailing Address - Country:US
Mailing Address - Phone:212-865-5899
Mailing Address - Fax:
Practice Address - Street 1:740 W END AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6246
Practice Address - Country:US
Practice Address - Phone:212-865-5899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011942-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV10061Medicare PIN