Provider Demographics
NPI:1093899007
Name:MARTIN, KENNETH LEON (MA, LPC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEON
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PACES BROOK AVE
Mailing Address - Street 2:APT 10518
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-1642
Mailing Address - Country:US
Mailing Address - Phone:803-467-4125
Mailing Address - Fax:803-497-3920
Practice Address - Street 1:105 PACES BROOK AVE
Practice Address - Street 2:#10518
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1642
Practice Address - Country:US
Practice Address - Phone:803-467-4125
Practice Address - Fax:803-497-3920
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4941101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health