Provider Demographics
NPI:1346584919
Name:MARTIN, KIMBERLY ANN (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 SICOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432-1756
Mailing Address - Country:US
Mailing Address - Phone:201-444-0142
Mailing Address - Fax:
Practice Address - Street 1:301 SICOMAC AVE
Practice Address - Street 2:CHRISTIAN HEALTHCARE CENTER
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481
Practice Address - Country:US
Practice Address - Phone:201-848-4323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00043600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ46TR00043600OtherLICENSE NUMBER