Healthcare Provider Details

I. General information

NPI: 1700333416
Provider Name (Legal Business Name): KIMBERLY RENEE MARTIN BCBA-D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY R MARTIN LBA

II. Dates (important events)

Enumeration Date: 09/10/2016
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W 1ST AVE STE C
OWASSO OK
74055-3137
US

IV. Provider business mailing address

PO BOX 740780
ATLANTA GA
30374-0780
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax:
Mailing address:
  • Phone: 855-223-7123
  • Fax: 619-374-7134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA0000000980
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-55013
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: