Provider Demographics
NPI:1255438362
Name:MARTIN, KENNETH SCOTT (CADC)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:SCOTT
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4940 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2270
Mailing Address - Country:US
Mailing Address - Phone:815-227-0081
Mailing Address - Fax:815-387-5316
Practice Address - Street 1:4940 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2270
Practice Address - Country:US
Practice Address - Phone:815-227-0081
Practice Address - Fax:815-387-5316
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL13193101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)