Provider Demographics
NPI:1508916420
Name:KOTECKI-MARTIN, JUDITH A (LCP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:KOTECKI-MARTIN
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 S 56TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66106-1523
Mailing Address - Country:US
Mailing Address - Phone:913-328-4631
Mailing Address - Fax:
Practice Address - Street 1:7840 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-2152
Practice Address - Country:US
Practice Address - Phone:913-328-4631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCP 026103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS3620000Medicare ID - Type Unspecified