Provider Demographics
NPI:1083138887
Name:MARTIN, RAVEN ANNELLE (DPT)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:ANNELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 SEQUOYA TRL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-8411
Mailing Address - Country:US
Mailing Address - Phone:615-417-4219
Mailing Address - Fax:
Practice Address - Street 1:5010 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-5074
Practice Address - Country:US
Practice Address - Phone:931-398-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist