Provider Demographics
NPI:1205962651
Name:MARTIN, MARY SWEETIE (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SWEETIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9711HORACEHARDINGEXPRESSWAY APARTMENT#15H
Mailing Address - Street 2:97-11 HORACE HARDING EXPRESSWAY APARTMENT #15H
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368
Mailing Address - Country:US
Mailing Address - Phone:718-699-9017
Mailing Address - Fax:
Practice Address - Street 1:97-11 HORACE HARDING EXPRESSWAY APARTMENT#15H
Practice Address - Street 2:97-11 HORACE HARDING EXPRESSWAY APARTMENT #15H
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:718-699-9017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0541671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR054167Medicare UPIN