Provider Demographics
NPI:1710133038
Name:MARTIN, KEVIN O
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:O
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 SPRING RD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-1421
Mailing Address - Country:US
Mailing Address - Phone:202-576-8936
Mailing Address - Fax:202-576-6122
Practice Address - Street 1:1125 SPRING RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-1421
Practice Address - Country:US
Practice Address - Phone:202-576-8936
Practice Address - Fax:202-576-6122
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPRC13640101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional