Provider Demographics
NPI:1235977927
Name:MARTIN, STACEY LOUISE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LOUISE
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 1:1061 OGDEN FARM RD
Mailing Address - Street 2:
Mailing Address - City:MOOREFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:26836-9012
Mailing Address - Country:US
Mailing Address - Phone:304-703-2917
Mailing Address - Fax:
Practice Address - Street 1:1061 OGDEN FARM RD
Practice Address - Street 2:
Practice Address - City:MOOREFIELD
Practice Address - State:WV
Practice Address - Zip Code:26836-9012
Practice Address - Country:US
Practice Address - Phone:304-703-2917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency