Provider Demographics
NPI:1144512310
Name:MARTIN, KRYSTAL L (LISW)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:L
Other - Last Name:PRESTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSW
Mailing Address - Street 1:338 GRANVILLE ST
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-2990
Mailing Address - Country:US
Mailing Address - Phone:614-475-7090
Mailing Address - Fax:614-475-5208
Practice Address - Street 1:338 GRANVILLE ST
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-2990
Practice Address - Country:US
Practice Address - Phone:614-475-7090
Practice Address - Fax:614-475-5208
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.10002931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical