Provider Demographics
NPI:1700407673
Name:MARTIN, KENNETH III (OTR/L)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MARTIN
Suffix:III
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6009 ZURICH DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-4527
Mailing Address - Country:US
Mailing Address - Phone:804-972-8010
Mailing Address - Fax:
Practice Address - Street 1:315 FIELD ST
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2105
Practice Address - Country:US
Practice Address - Phone:770-537-4482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-02
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119-008582225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist