Provider Demographics
NPI:1750973053
Name:AUDREY L. MARTIN LLC
Entity type:Organization
Organization Name:AUDREY L. MARTIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-644-2944
Mailing Address - Street 1:23527 SYCAMORE HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-8215
Mailing Address - Country:US
Mailing Address - Phone:316-644-2944
Mailing Address - Fax:
Practice Address - Street 1:303 N WEST ST STE 220
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-1269
Practice Address - Country:US
Practice Address - Phone:316-302-4988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200656430BMedicaid