Provider Demographics
NPI:1710534177
Name:MARTIN, MATTHEW K
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:K
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 1:205 PEARL ST APT A
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1742
Mailing Address - Country:US
Mailing Address - Phone:270-597-7076
Mailing Address - Fax:
Practice Address - Street 1:363 W LINCOLN TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-3302
Practice Address - Country:US
Practice Address - Phone:270-352-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician