Provider Demographics
NPI:1699136788
Name:KIMBERLY M MARTIN, PSY.D. LLC
Entity type:Organization
Organization Name:KIMBERLY M MARTIN, PSY.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:317-721-9067
Mailing Address - Street 1:3650 E 46TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1610
Mailing Address - Country:US
Mailing Address - Phone:317-721-9067
Mailing Address - Fax:
Practice Address - Street 1:3650 E 46TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1610
Practice Address - Country:US
Practice Address - Phone:317-721-9067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042486A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400057769Medicare PIN