Provider Demographics
NPI:1356040414
Name:MARTIN, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
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 1:229059 CHICKEN LN
Mailing Address - Street 2:
Mailing Address - City:MARATHON
Mailing Address - State:WI
Mailing Address - Zip Code:54448-2406
Mailing Address - Country:US
Mailing Address - Phone:715-803-3258
Mailing Address - Fax:
Practice Address - Street 1:530 GRANT ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-4738
Practice Address - Country:US
Practice Address - Phone:715-845-5493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health