Provider Demographics
NPI:1245261809
Name:MARTIN, KENNETH J (MFT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125A NOE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-1218
Mailing Address - Country:US
Mailing Address - Phone:415-395-9367
Mailing Address - Fax:415-552-5934
Practice Address - Street 1:564 MARKET ST
Practice Address - Street 2:SUITE 410
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94104-5404
Practice Address - Country:US
Practice Address - Phone:415-395-9367
Practice Address - Fax:415-552-5934
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35253106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist