Provider Demographics
NPI:1316048549
Name:MARTIN, PATRICIA PETERS (PH D)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:PETERS
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1530
Mailing Address - Country:US
Mailing Address - Phone:413-567-0380
Mailing Address - Fax:413-567-0380
Practice Address - Street 1:1200 CONVERSE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1760
Practice Address - Country:US
Practice Address - Phone:413-567-0380
Practice Address - Fax:413-567-0380
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3971103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO 3964Medicare ID - Type Unspecified