Provider Demographics
NPI:1417227364
Name:BAHE, MARTY W (AA)
Entity Type:Individual
Prefix:MR
First Name:MARTY
Middle Name:W
Last Name:BAHE
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:1 MILE NORTH ON HIGHWAY 163
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-0487
Mailing Address - Country:US
Mailing Address - Phone:928-697-5570
Mailing Address - Fax:928-697-5574
Practice Address - Street 1:1 MILE NORTH ON HIGHWAY 163
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033-0487
Practice Address - Country:US
Practice Address - Phone:928-697-5570
Practice Address - Fax:928-697-5574
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC - 11443101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)