Provider Demographics
NPI:1831823665
Name:MARTIN, KENNETH BLAIR JR (LMSW)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:BLAIR
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 PORTAGE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1774
Mailing Address - Country:US
Mailing Address - Phone:269-718-3366
Mailing Address - Fax:
Practice Address - Street 1:5900 PORTAGE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1774
Practice Address - Country:US
Practice Address - Phone:269-718-3366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801058849104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker