Provider Demographics
NPI:1902862873
Name:MARTIN, KIM ELLEN (OTL CHT)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:ELLEN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OTL CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3466 PINE RIDGE RD STE A
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-3883
Mailing Address - Country:US
Mailing Address - Phone:239-261-2663
Mailing Address - Fax:239-262-5633
Practice Address - Street 1:3466 PINE RIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-3883
Practice Address - Country:US
Practice Address - Phone:239-261-2663
Practice Address - Fax:239-262-5633
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0244225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0460790OtherBCBS
P00107Medicare UPIN
61076Medicare ID - Type Unspecified