Provider Demographics
NPI:1821309576
Name:MARTIN, MARY ELLEN (MFT)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 COUNTRY ESTATES LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-3001
Mailing Address - Country:US
Mailing Address - Phone:505-604-2512
Mailing Address - Fax:505-342-5414
Practice Address - Street 1:1218 GRIEGOS RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-3752
Practice Address - Country:US
Practice Address - Phone:505-345-8471
Practice Address - Fax:505-342-5414
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
COMFT.0001249106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst