Provider Demographics
NPI:1326148594
Name:MARTINS, KENNETH (LP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MARTINS
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-3605
Mailing Address - Country:US
Mailing Address - Phone:507-388-8114
Mailing Address - Fax:507-388-8068
Practice Address - Street 1:302 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3605
Practice Address - Country:US
Practice Address - Phone:507-388-8114
Practice Address - Fax:507-388-8068
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2702103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN136327Medicaid
MN30407-01OtherVALUE OPTIONS
MNHP42906OtherHEALTH PARTNERS
MN473T4MAOtherMN BCBS