Provider Demographics
NPI:1447664701
Name:MARTINIE, MAXINE (MFT)
Entity type:Individual
Prefix:MS
First Name:MAXINE
Middle Name:
Last Name:MARTINIE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1172
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-0040
Mailing Address - Country:US
Mailing Address - Phone:541-708-7755
Mailing Address - Fax:
Practice Address - Street 1:321 CLAY ST SPC 63
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-7379
Practice Address - Country:US
Practice Address - Phone:541-708-7755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-15
Last Update Date:2014-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR T0846106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist