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General NPI Number Information
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NPI Number | 1831791789
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Entity Type | Individual
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Provider Name | TYKEQA MICHELLE MARTIN
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Gender | Female
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Dates
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Enumeration Date | 11/14/2020
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Last Update Date | 11/14/2020
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Provider Practice Location Address
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Address Line | 285 MIAMI AVE
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City | COLUMBUS
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State | OH
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Zip | 43203-1513
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Country | US
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Telephone | 614-973-2970
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Fax |
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Provider Business Mailing Address
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Address Line | 700 BRYDEN RD STE 561
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City | COLUMBUS
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State | OH
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Zip | 43215-4839
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Country | US
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Telephone | 614-973-2970
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number | 85-2853696
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License Number State | OH
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