Healthcare Provider Details

I. General information

NPI: 1154877546
Provider Name (Legal Business Name): KRISTEN M MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 POLK ST SUITE 300
WATERTOWN NY
13601-2097
US

IV. Provider business mailing address

PO BOX 6550
WATERTOWN NY
13601-6550
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7445
  • Fax: 315-779-1184
Mailing address:
  • Phone: 315-782-7445
  • Fax: 315-779-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number006184-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: