Provider Demographics
NPI:1073925046
Name:MARTIN, KENDALL
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
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 1:3191 CHURN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-2123
Mailing Address - Country:US
Mailing Address - Phone:530-224-7160
Mailing Address - Fax:530-224-7168
Practice Address - Street 1:3191 CHURN CREEK RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2123
Practice Address - Country:US
Practice Address - Phone:530-224-7160
Practice Address - Fax:530-224-7168
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1200704101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2296215Medicaid
OH2296215Medicaid