=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750973053
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUDREY L. MARTIN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2021
-----------------------------------------------------
Last Update Date | 09/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 N WEST ST STE 220
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67203-1269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-302-4988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23527 SYCAMORE HEIGHTS RD
-----------------------------------------------------
City | SILOAM SPRINGS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72761-8215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-644-2944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AUDREY MARTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 316-644-2944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------