Provider Demographics
NPI:1043675879
Name:MARTIN, COURTNEY (PTA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10866 E COUNTY ROAD 600N
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-8481
Mailing Address - Country:US
Mailing Address - Phone:217-234-7128
Mailing Address - Fax:
Practice Address - Street 1:10866 E COUNTY ROAD 600N
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-8481
Practice Address - Country:US
Practice Address - Phone:217-234-7128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.002143225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant