Provider Demographics
NPI:1144769274
Name:GARY, MARTHA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:GARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CANEYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42721-9060
Mailing Address - Country:US
Mailing Address - Phone:270-230-7738
Mailing Address - Fax:
Practice Address - Street 1:527 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:CANEYVILLE
Practice Address - State:KY
Practice Address - Zip Code:42721-9060
Practice Address - Country:US
Practice Address - Phone:270-230-7738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician