Provider Demographics
NPI:1558147793
Name:MARTIN, KYOTO
Entity Type:Individual
Prefix:
First Name:KYOTO
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 PALMETTO PARK BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7969
Mailing Address - Country:US
Mailing Address - Phone:803-361-0867
Mailing Address - Fax:
Practice Address - Street 1:1557 OLD ORANGEBURG RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073-8486
Practice Address - Country:US
Practice Address - Phone:803-361-0867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health