Provider Demographics
NPI:1700319977
Name:MCMARTIN, KELLY JO (LPCC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:MCMARTIN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:SCHULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:#110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3833 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 120
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2643
Practice Address - Country:US
Practice Address - Phone:763-767-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01423101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional