Provider Demographics
NPI:1750667796
Name:MARTIN, STEPHANIE DIANNE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANNE
Last Name:MARTIN
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 1:4747 N 7TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-3653
Mailing Address - Country:US
Mailing Address - Phone:602-279-7655
Mailing Address - Fax:602-264-1806
Practice Address - Street 1:1255 W BASELINE RD
Practice Address - Street 2:SUITE B258
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5820
Practice Address - Country:US
Practice Address - Phone:480-820-0825
Practice Address - Fax:480-820-7863
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health