Provider Demographics
NPI:1831817493
Name:MARTIN, STACY (ADCA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ADCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 ODLIN RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6709
Mailing Address - Country:US
Mailing Address - Phone:207-947-6800
Mailing Address - Fax:
Practice Address - Street 1:689 ODLIN RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6709
Practice Address - Country:US
Practice Address - Phone:207-947-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAD8162101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)