Basic Information
| Provider Information | |||||||||
| NPI: | 1093870446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILGORE | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | L.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 5TH AVE NW | ||||||||
| Address2: | |||||||||
| City: | ATTALLA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359542214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564927800 | ||||||||
| FaxNumber: | 2564945536 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 14TH ST NW | ||||||||
| Address2: | |||||||||
| City: | FT. PAYNE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359673155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568454571 | ||||||||
| FaxNumber: | 2568454582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 09/26/2011 | ||||||||
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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 | 101YP2500X | 2005 | AL | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 2005AL | AL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.