Provider Demographics
NPI:1861843245
Name:MARTIN, KORY
Entity Type:Individual
Prefix:
First Name:KORY
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 1:2658 ALABAMA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1761
Mailing Address - Country:US
Mailing Address - Phone:651-434-3795
Mailing Address - Fax:
Practice Address - Street 1:200 4TH AVE W
Practice Address - Street 2:GOVERNMENT CENTER SUITE 300
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1220
Practice Address - Country:US
Practice Address - Phone:952-496-8481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLAMFT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist