Provider Demographics
NPI:1679110217
Name:MARTIN, KRISTIN ANNE (LMHC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:ANNE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14640 BUTTERCUP LN
Mailing Address - Street 2:
Mailing Address - City:LETTS
Mailing Address - State:IA
Mailing Address - Zip Code:52754-9311
Mailing Address - Country:US
Mailing Address - Phone:563-554-4821
Mailing Address - Fax:563-454-5453
Practice Address - Street 1:312 IOWA AVE
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-3836
Practice Address - Country:US
Practice Address - Phone:563-320-7050
Practice Address - Fax:563-424-5453
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073985101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health