Provider Demographics
NPI:1902120850
Name:MARTENSEN, KYLA M (LMST)
Entity Type:Individual
Prefix:MS
First Name:KYLA
Middle Name:M
Last Name:MARTENSEN
Suffix:
Gender:F
Credentials:LMST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 N LINCOLN PARK W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4649
Mailing Address - Country:US
Mailing Address - Phone:773-266-1232
Mailing Address - Fax:
Practice Address - Street 1:2130 N LINCOLN PARK W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4649
Practice Address - Country:US
Practice Address - Phone:773-266-1232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227002487225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist