Provider Demographics
NPI:1548566029
Name:NACY, MARTHA BRIDGET (LLP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:BRIDGET
Last Name:NACY
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12851 GRAND RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-8506
Mailing Address - Country:US
Mailing Address - Phone:810-227-1211
Mailing Address - Fax:810-220-5509
Practice Address - Street 1:5841 WHITMORE LAKE RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116
Practice Address - Country:US
Practice Address - Phone:810-227-6218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-02456103TA0400X
MI6301005605103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
13854015OtherCAQH
MI6301005605OtherLLP