Provider Demographics
NPI:1740617430
Name:KNIFFIN, MARTHA DARLENE
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:DARLENE
Last Name:KNIFFIN
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 398
Mailing Address - Street 2:
Mailing Address - City:NEW GLARUS
Mailing Address - State:WI
Mailing Address - Zip Code:53574-0398
Mailing Address - Country:US
Mailing Address - Phone:608-438-0982
Mailing Address - Fax:
Practice Address - Street 1:1805 EXCELSIOR DR
Practice Address - Street 2:THE FAMILY CENTER
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717
Practice Address - Country:US
Practice Address - Phone:608-663-6154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI362-228106H00000X
WI106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist