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General NPI Number Information
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NPI Number | 1861211906
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Entity Type | Individual
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Provider Name | KIMBERLY DAIANNA MARTIN LAC
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Gender | Female
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Dates
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Enumeration Date | 10/07/2024
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Last Update Date | 10/07/2024
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Provider Practice Location Address
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Address Line | 6 GATES AVENUE
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City | MONTCLAIR
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State | NJ
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Zip | 07042
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Country | US
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Telephone | 973-604-6881
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Fax |
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Provider Business Mailing Address
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Address Line | 53 PIAGET AVE
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City | CLIFTON
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State | NJ
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Zip | 07011-1216
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Country | US
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Telephone |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 37AC00757100
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License Number State | NJ
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