Provider Demographics
NPI:1760688907
Name:MARTIN, STACY (MA, BCBA, COBA)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA, BCBA, COBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:882 EASTCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-5137
Mailing Address - Country:US
Mailing Address - Phone:919-771-3930
Mailing Address - Fax:
Practice Address - Street 1:882 EASTCHESTER DR
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-5137
Practice Address - Country:US
Practice Address - Phone:919-771-3930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst