Provider Demographics
NPI:1093230229
Name:MARTIN, REBECCA ANN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
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 1:200 HALLAHAN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:12967-9788
Mailing Address - Country:US
Mailing Address - Phone:570-259-4673
Mailing Address - Fax:
Practice Address - Street 1:49 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1889
Practice Address - Country:US
Practice Address - Phone:315-264-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034114-12251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology