Provider Demographics
NPI:1164695433
Name:MARTIN, KRISTIE (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-4563
Mailing Address - Country:US
Mailing Address - Phone:580-255-4323
Mailing Address - Fax:580-470-9981
Practice Address - Street 1:1105 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-4563
Practice Address - Country:US
Practice Address - Phone:580-255-4323
Practice Address - Fax:580-470-9981
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical