Provider Demographics
NPI:1013241264
Name:MARTIN, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
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 1:251 FLEET ST
Mailing Address - Street 2:
Mailing Address - City:RANKIN
Mailing Address - State:PA
Mailing Address - Zip Code:15104-1150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 FLEET ST
Practice Address - Street 2:
Practice Address - City:RANKIN
Practice Address - State:PA
Practice Address - Zip Code:15104-1150
Practice Address - Country:US
Practice Address - Phone:412-519-2980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health