Provider Demographics
NPI:1073026589
Name:MARTIN, RAITHEL JEAN (MSE, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:RAITHEL
Middle Name:JEAN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MSE, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 N LOVINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-9120
Mailing Address - Country:US
Mailing Address - Phone:210-213-0147
Mailing Address - Fax:
Practice Address - Street 1:405 NW 3RD ST
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:TX
Practice Address - Zip Code:79714-5014
Practice Address - Country:US
Practice Address - Phone:432-523-3640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
TXAT74392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT7439OtherTEXAS STATE AT LICENSE
2000030454OtherBOC NATIONAL CERTIFICATION