Provider Demographics
NPI:1083029342
Name:MARTIN, JUDITH TIA (LMP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:TIA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28611 6TH PL S
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-8230
Mailing Address - Country:US
Mailing Address - Phone:253-377-8933
Mailing Address - Fax:
Practice Address - Street 1:751 NE BLAKELY DR
Practice Address - Street 2:SUITE 3020
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-6201
Practice Address - Country:US
Practice Address - Phone:253-377-8933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60491363225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist