Provider Demographics
NPI:1578383659
Name:SWEENEY, MARTINA
Entity type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:SWEENEY
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 1:4575 NATHAN LN N APT 210
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-3197
Mailing Address - Country:US
Mailing Address - Phone:612-749-0807
Mailing Address - Fax:
Practice Address - Street 1:2812 FAIRVIEW AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1308
Practice Address - Country:US
Practice Address - Phone:612-345-7306
Practice Address - Fax:612-587-1103
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician