Provider Demographics
NPI:1750116778
Name:MARTIN, KALI RAE (RBT)
Entity type:Individual
Prefix:
First Name:KALI
Middle Name:RAE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 KELLY LN
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-9509
Mailing Address - Country:US
Mailing Address - Phone:815-761-6550
Mailing Address - Fax:
Practice Address - Street 1:1749 S RANDALL RD STE A
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4616
Practice Address - Country:US
Practice Address - Phone:630-931-7589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-23-265528106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty