Provider Demographics
NPI:1144787110
Name:MARTIN, CARLYE J (COTA)
Entity Type:Individual
Prefix:
First Name:CARLYE
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 VERANO ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355-6921
Mailing Address - Country:US
Mailing Address - Phone:901-413-7578
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:2865 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-3070
Practice Address - Country:US
Practice Address - Phone:731-784-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3190224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant