Provider Demographics
NPI:1588718928
Name:MARTIN, HOLLY JEAN (MA, CCDP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:JEAN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA, CCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 LINDEN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-4838
Mailing Address - Country:US
Mailing Address - Phone:724-413-5726
Mailing Address - Fax:724-225-7354
Practice Address - Street 1:800 MANOR DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-2967
Practice Address - Country:US
Practice Address - Phone:724-413-5726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007004L103T00000X
PA5824103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01804231Medicare ID - Type Unspecified