Provider Demographics
NPI:1821129396
Name:BRISKY, MARTHA T (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:T
Last Name:BRISKY
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:HC 61 BOX 5069
Mailing Address - Street 2:
Mailing Address - City:RAMAH
Mailing Address - State:NM
Mailing Address - Zip Code:87321-9609
Mailing Address - Country:US
Mailing Address - Phone:505-240-1545
Mailing Address - Fax:
Practice Address - Street 1:154 EL MORRO WAY N
Practice Address - Street 2:
Practice Address - City:RAMAH
Practice Address - State:NM
Practice Address - Zip Code:87321
Practice Address - Country:US
Practice Address - Phone:505-240-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM248115103TS0200X
NM556103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG9802Medicaid