Provider Demographics
NPI:1598994972
Name:COURSEY, MARTHA M
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:M
Last Name:COURSEY
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 1:867 SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:ISLAND FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04747-4413
Mailing Address - Country:US
Mailing Address - Phone:207-463-2757
Mailing Address - Fax:
Practice Address - Street 1:867 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:ISLAND FALLS
Practice Address - State:ME
Practice Address - Zip Code:04747-4413
Practice Address - Country:US
Practice Address - Phone:207-463-2757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME216650000Medicaid
ME27-0500940OtherEIN