Provider Demographics
NPI:1336983600
Name:MARTIN, STEPHEN KINZER
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:KINZER
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PLEASANT ST UNIT 2F
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-3217
Mailing Address - Country:US
Mailing Address - Phone:978-602-4761
Mailing Address - Fax:
Practice Address - Street 1:30 PLEASANT ST UNIT 2F
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-3217
Practice Address - Country:US
Practice Address - Phone:978-602-4761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health