Provider Demographics
NPI:1386907798
Name:MARTIN, ALISA (MS ED)
Entity type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 MONTAGUE STREET,
Mailing Address - Street 2:SUITE #341
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201
Mailing Address - Country:US
Mailing Address - Phone:646-271-6773
Mailing Address - Fax:718-625-1027
Practice Address - Street 1:137 MONTAGUE STREET,
Practice Address - Street 2:SUITE #341
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:646-271-6773
Practice Address - Fax:718-625-1027
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175306.174400000X
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No252Y00000XAgenciesEarly Intervention Provider Agency