Provider Demographics
NPI:1366717415
Name:MARTIN, KRISTINE LYNN (MA LPCC)
Entity type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 W 54TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1513
Mailing Address - Country:US
Mailing Address - Phone:612-824-0856
Mailing Address - Fax:612-668-4405
Practice Address - Street 1:250 S 4TH ST
Practice Address - Street 2:PSC ROOM 510
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1335
Practice Address - Country:US
Practice Address - Phone:612-673-2301
Practice Address - Fax:612-668-4405
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00463101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional