Provider Demographics
NPI:1629397617
Name:MARTIN, KIMBERLY M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 M ST SE STE 600
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-3648
Mailing Address - Country:US
Mailing Address - Phone:317-721-9067
Mailing Address - Fax:
Practice Address - Street 1:100 M ST SE STE 600
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-3648
Practice Address - Country:US
Practice Address - Phone:317-721-9067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-31
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810006455103TC0700X
IN20042486A103TC0700X
DCPSY1001716103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400057769Medicare PIN