Provider Demographics
NPI:1992885735
Name:KITZROW, MARTHA A (PHD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:A
Last Name:KITZROW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E 3RD ST STE 6
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2970
Mailing Address - Country:US
Mailing Address - Phone:208-883-1842
Mailing Address - Fax:208-885-4354
Practice Address - Street 1:106 E 3RD ST STE 6
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2970
Practice Address - Country:US
Practice Address - Phone:208-883-1842
Practice Address - Fax:208-885-4354
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID255103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1680544Medicare ID - Type Unspecified