Provider Demographics
NPI:1407297740
Name:WELCH, MARTHA JANE (PSYD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:JANE
Last Name:WELCH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 E STATE ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2901
Mailing Address - Country:US
Mailing Address - Phone:866-874-5381
Mailing Address - Fax:815-261-5963
Practice Address - Street 1:5301 E STATE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2901
Practice Address - Country:US
Practice Address - Phone:866-874-5381
Practice Address - Fax:815-261-5963
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008572103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical