Provider Demographics
NPI:1437776358
Name:MARTIN, KEZIA FAYE (MS)
Entity Type:Individual
Prefix:
First Name:KEZIA
Middle Name:FAYE
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 E ROYAL LN STE 290
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3602
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:722-675-9100
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12044318103K00000X
ILRBT-20-112895106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician