Provider Demographics
NPI:1407189038
Name:DRIFFIN, MARTHA R
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:R
Last Name:DRIFFIN
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 1:232 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1610
Mailing Address - Country:US
Mailing Address - Phone:203-503-3300
Mailing Address - Fax:203-401-3352
Practice Address - Street 1:232 CEDAR ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1610
Practice Address - Country:US
Practice Address - Phone:203-503-3300
Practice Address - Fax:203-401-3352
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235918Medicaid