Provider Demographics
NPI:1700333416
Name:MARTIN, KIMBERLY RENEE (MS)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:RENEE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:R
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LBA
Mailing Address - Street 1:2210 N ELDORADO AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6418
Mailing Address - Country:US
Mailing Address - Phone:541-883-1030
Mailing Address - Fax:541-884-2338
Practice Address - Street 1:2210 N ELDORADO AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6418
Practice Address - Country:US
Practice Address - Phone:541-883-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-10
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FL103K00000X
TNLBA0000000980103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health