Basic Information
| Provider Information | |||||||||
| NPI: | 1659727725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | RESOURCE MANAGEMENT | ||||||||
| Address2: | 210 E. MAIN ST | ||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804367211 | ||||||||
| FaxNumber: | 5802725757 | ||||||||
| Practice Location | |||||||||
| Address1: | MEDICAL FAMILY THERAPY | ||||||||
| Address2: | 2510 CHICKASAW BLVD. | ||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802222884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2016 | ||||||||
| LastUpdateDate: | 03/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1007328830 | 05 | OK | MEDICAID |