Provider Demographics
NPI:1053008169
Name:MARTIN, ANTOINETTE MARIE (TCADC)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9702 STONESTREET RD STE 120
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-6812
Practice Address - Country:US
Practice Address - Phone:866-934-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY282757101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)