Provider Demographics
NPI:1023563665
Name:MARTIN, MICHAELA
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
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 1:1653 HILLSBORO RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40011-6513
Mailing Address - Country:US
Mailing Address - Phone:502-554-2006
Mailing Address - Fax:
Practice Address - Street 1:2865 CHANCELLOR DR
Practice Address - Street 2:SUITE 105
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3912
Practice Address - Country:US
Practice Address - Phone:859-426-5666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA035507225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant