Provider Demographics
NPI:1215738620
Name:MARTIN, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 LETITIA LN
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-4019
Mailing Address - Country:US
Mailing Address - Phone:484-645-0383
Mailing Address - Fax:
Practice Address - Street 1:13 LETITIA LN
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-4019
Practice Address - Country:US
Practice Address - Phone:484-645-0383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-21
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6350891101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool