Provider Demographics
NPI:1356039150
Name:MARTIN, KRISTEN NICOLE CODY
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE CODY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2218 INSPIRATION LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2859
Mailing Address - Country:US
Mailing Address - Phone:719-404-6860
Mailing Address - Fax:
Practice Address - Street 1:225 E CHEYENNE MOUNTAIN BLVD STE 100A
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3700
Practice Address - Country:US
Practice Address - Phone:719-493-8843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-28
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health