Provider Demographics
NPI:1639397201
Name:MARTIN, MARY ELAINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELAINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
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 23
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-0023
Mailing Address - Country:US
Mailing Address - Phone:518-439-3844
Mailing Address - Fax:518-439-3844
Practice Address - Street 1:75 NEW SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3409
Practice Address - Country:US
Practice Address - Phone:518-447-9611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical