Provider Demographics
NPI:1164702916
Name:MARTIN, BRENDA J (LMT, CCA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMT, CCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 ROUTE 82
Mailing Address - Street 2:
Mailing Address - City:ANCRAM
Mailing Address - State:NY
Mailing Address - Zip Code:12502-5120
Mailing Address - Country:US
Mailing Address - Phone:845-702-2066
Mailing Address - Fax:
Practice Address - Street 1:7476 S BROADWAY
Practice Address - Street 2:
Practice Address - City:RED HOOK
Practice Address - State:NY
Practice Address - Zip Code:12571-1772
Practice Address - Country:US
Practice Address - Phone:845-702-2066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016543-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist