Provider Demographics
NPI:1497809826
Name:MACERONI, MARTHA G (MSW)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:G
Last Name:MACERONI
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:MARTHA
Other - Middle Name:GERALYN
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:19911 BLACKFOOT DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:517-230-5858
Mailing Address - Fax:
Practice Address - Street 1:39949 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:517-230-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010001581041C0700X
MI41010005185106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM85260Medicare ID - Type Unspecified
MI0890205Medicare ID - Type Unspecified