Provider Demographics
NPI:1467437608
Name:COLLETTE, MARTHA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:ANN
Last Name:COLLETTE
Suffix:
Gender:F
Credentials:PHD
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 237
Mailing Address - Street 2:
Mailing Address - City:PRIDES CROSSING
Mailing Address - State:MA
Mailing Address - Zip Code:01965-0237
Mailing Address - Country:US
Mailing Address - Phone:978-922-2046
Mailing Address - Fax:978-927-1946
Practice Address - Street 1:24 NEPTUNE ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-4726
Practice Address - Country:US
Practice Address - Phone:978-921-5080
Practice Address - Fax:978-927-1946
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2347103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0507253Medicaid
MA0507253Medicaid