Provider Demographics
NPI:1619187325
Name:SIMON, MARTHA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:SIMON
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:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0528
Mailing Address - Country:US
Mailing Address - Phone:907-543-6100
Mailing Address - Fax:907-543-6008
Practice Address - Street 1:OLD LIBRARY BLDG.
Practice Address - Street 2:
Practice Address - City:HOOPER BAY
Practice Address - State:AK
Practice Address - Zip Code:99604
Practice Address - Country:US
Practice Address - Phone:907-758-4811
Practice Address - Fax:907-758-4065
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDA4442Medicaid