Provider Demographics
NPI:1538212121
Name:MARTIN, MARY ELLEN (LAC)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:ELLEN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
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Mailing Address - Street 1:17 MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-1306
Mailing Address - Country:US
Mailing Address - Phone:646-942-8164
Mailing Address - Fax:631-928-2045
Practice Address - Street 1:1015 W BEECH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-1203
Practice Address - Country:US
Practice Address - Phone:646-942-8164
Practice Address - Fax:631-928-2045
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY25002586171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist