Provider Demographics
NPI:1912583097
Name:MARTIN, KATHERYN A
Entity Type:Individual
Prefix:
First Name:KATHERYN
Middle Name:A
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 1:4000 LAKE UNDERHILL RD APT U
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-7054
Mailing Address - Country:US
Mailing Address - Phone:346-899-6767
Mailing Address - Fax:
Practice Address - Street 1:1621 E VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-3730
Practice Address - Country:US
Practice Address - Phone:407-847-4152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6229317201OtherCIGNA