Provider Demographics
NPI:1760509855
Name:MARTIN, MARI C (MSE)
Entity Type:Individual
Prefix:MS
First Name:MARI
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 E MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-3764
Mailing Address - Country:US
Mailing Address - Phone:920-469-8890
Mailing Address - Fax:920-406-3909
Practice Address - Street 1:2345 E MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3764
Practice Address - Country:US
Practice Address - Phone:920-469-8890
Practice Address - Fax:920-406-3909
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1951-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39699800Medicaid