Provider Demographics
NPI:1417331380
Name:MARTIN, MARYANN
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:MARTIN
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 1:1755 N PEBBLE CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2532
Mailing Address - Country:US
Mailing Address - Phone:623-556-7459
Mailing Address - Fax:
Practice Address - Street 1:3907 S 186TH LN
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-7641
Practice Address - Country:US
Practice Address - Phone:623-556-7459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101Y00000X
AZLPC-22218101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor