Provider Demographics
NPI:1760145668
Name:MARTIN, KEITH
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
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 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4528
Mailing Address - Country:US
Mailing Address - Phone:518-593-7853
Mailing Address - Fax:
Practice Address - Street 1:80 SHARRON AVE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-4700
Practice Address - Country:US
Practice Address - Phone:518-561-1447
Practice Address - Fax:518-562-8812
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112598-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health