Provider Demographics
NPI:1407952278
Name:MARTIN NISLY, KEVIN R (LMSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:MARTIN NISLY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N LORRAINE ST
Mailing Address - Street 2:STE 202
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67501-5600
Mailing Address - Country:US
Mailing Address - Phone:620-200-2023
Mailing Address - Fax:
Practice Address - Street 1:1600 N LORRAINE ST
Practice Address - Street 2:STE 202
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67501-5600
Practice Address - Country:US
Practice Address - Phone:620-200-2023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4738104100000X
KS37371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100098120AMedicaid