Healthcare Provider Details

I. General information

NPI: 1871045674
Provider Name (Legal Business Name): K'DESHIA ZHANE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: K'DESHIA MARTIN

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W I 240 SERVICE RD
OKLAHOMA CITY OK
73139-7701
US

IV. Provider business mailing address

5517 EVANBROOK TER
OKLAHOMA CITY OK
73135-1523
US

V. Phone/Fax

Practice location:
  • Phone: 405-635-3800
  • Fax: 405-604-9689
Mailing address:
  • Phone: 405-546-8060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10099
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: