Provider Demographics
NPI:1275182610
Name:MARTIN, KIRSTEN MARIE (MS)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15200 S JOG RD STE 303
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-1249
Mailing Address - Country:US
Mailing Address - Phone:561-503-3059
Mailing Address - Fax:
Practice Address - Street 1:15200 S JOG RD STE 303
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-1249
Practice Address - Country:US
Practice Address - Phone:561-503-3059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH18746101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health