Provider Demographics
NPI:1578630984
Name:MARTIN, KATHY (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W LAKE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4527
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:3100 W LAKE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4527
Practice Address - Country:US
Practice Address - Phone:612-925-6033
Practice Address - Fax:612-925-8496
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN90111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN411425197OtherCIGNA BEHAVIORAL HEALTH
MN843521900Medicaid
MNHP19963OtherHEALTHPARTNERS
MN6234667OtherMEDICA CHOICE
MN111570C154OtherUCARE
MN800004028OtherRR MEDICARE
MN9H390MAOtherBCBS
MN9H390MAOtherBCBS