Provider Demographics
NPI:1366882979
Name:MA, MARTHA (LAC, MS)
Entity type:Individual
Prefix:PROF
First Name:MARTHA
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:LAC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 1ST AVE APT 707
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-4328
Mailing Address - Country:US
Mailing Address - Phone:917-309-4694
Mailing Address - Fax:
Practice Address - Street 1:83 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-2423
Practice Address - Country:US
Practice Address - Phone:917-309-4694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT590171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist