Provider Demographics
NPI:1831791789
Name:MARTIN, TYKEQA MICHELLE
Entity type:Individual
Prefix:
First Name:TYKEQA
Middle Name:MICHELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BRYDEN RD STE 561
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4839
Mailing Address - Country:US
Mailing Address - Phone:614-973-2970
Mailing Address - Fax:
Practice Address - Street 1:285 MIAMI AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-1513
Practice Address - Country:US
Practice Address - Phone:614-973-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH85-2853696103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service