Provider Demographics
NPI:1013546043
Name:MARTIN, KRYSTAL MARIE
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3404 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71302-3805
Mailing Address - Country:US
Mailing Address - Phone:318-406-1636
Mailing Address - Fax:
Practice Address - Street 1:3600 JACKSON ST STE 111B
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3000
Practice Address - Country:US
Practice Address - Phone:318-792-8448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health