Basic Information
| Provider Information | |||||||||
| NPI: | 1871045674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | K'DESHIA | ||||||||
| MiddleName: | ZHANE | ||||||||
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| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | K'DESHIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5517 EVANBROOK TER | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731351523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055468060 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 W I 240 SERVICE RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731397701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056353800 | ||||||||
| FaxNumber: | 4056049689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2016 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | 10099 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.