Provider Demographics
NPI:1477843241
Name:WARD, MARTIN KELLY (PLPC)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:KELLY
Last Name:WARD
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2037 S HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7635
Mailing Address - Country:US
Mailing Address - Phone:417-894-2071
Mailing Address - Fax:
Practice Address - Street 1:304 W ERIE ST STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4915
Practice Address - Country:US
Practice Address - Phone:417-881-7151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011009728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional