Provider Demographics
NPI:1477117760
Name:ANDERSON, MARTHA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:ANDERSON
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 1:616 FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:LAURIUM
Mailing Address - State:MI
Mailing Address - Zip Code:49913-2210
Mailing Address - Country:US
Mailing Address - Phone:906-370-7709
Mailing Address - Fax:
Practice Address - Street 1:4750 COLLEGIATE DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-1000
Practice Address - Country:US
Practice Address - Phone:850-770-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7402000113106E00000X
106S00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician