Provider Demographics
NPI:1154689115
Name:MCKINNON, MARTA SMITH (MED)
Entity Type:Individual
Prefix:MRS
First Name:MARTA
Middle Name:SMITH
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 DORSET COURT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:KY
Mailing Address - Zip Code:40026
Mailing Address - Country:US
Mailing Address - Phone:502-292-0790
Mailing Address - Fax:
Practice Address - Street 1:1700 UPS DR STE 107
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4046
Practice Address - Country:US
Practice Address - Phone:502-330-4511
Practice Address - Fax:502-339-4513
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11-26106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist