Healthcare Provider Details

I. General information

NPI: 1760145668
Provider Name (Legal Business Name): MR. KEITH MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 ROUTE 22B
MORRISONVILLE NY
12962-3417
US

IV. Provider business mailing address

416 STAFFORD RD
PLATTSBURGH NY
12901-6121
US

V. Phone/Fax

Practice location:
  • Phone: 518-563-8000
  • Fax: 518-324-2178
Mailing address:
  • Phone: 518-593-7853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number41497
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number017636
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: