Provider Demographics
NPI:1104581354
Name:KPEHE, MARTIN
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:KPEHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8875 STAGHORN ML
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3564
Mailing Address - Country:US
Mailing Address - Phone:210-984-7529
Mailing Address - Fax:
Practice Address - Street 1:8875 STAGHORN ML
Practice Address - Street 2:
Practice Address - City:CONVERSE
Practice Address - State:TX
Practice Address - Zip Code:78109-3564
Practice Address - Country:US
Practice Address - Phone:210-984-7529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health