Provider Demographics
NPI:1649508946
Name:MARTIN, STEPHANIE ANNE (PSYD, HSPP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5202 BROOKLINE DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-5160
Mailing Address - Country:US
Mailing Address - Phone:219-688-3514
Mailing Address - Fax:
Practice Address - Street 1:601 WALL ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2512
Practice Address - Country:US
Practice Address - Phone:219-476-4577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042508A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical