Provider Demographics
NPI:1861031148
Name:MARTIN, KENNETH NOEL (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:NOEL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 SLAYTON DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3627
Mailing Address - Country:US
Mailing Address - Phone:309-838-7777
Mailing Address - Fax:
Practice Address - Street 1:616 IAA DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-2225
Practice Address - Country:US
Practice Address - Phone:309-838-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015534101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health