Provider Demographics
NPI:1174687263
Name:MARTIN, KELLY CATHERINE (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CATHERINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARTIN
Other - Last Name:HOWZE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2627 SISKIYOU BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8188
Mailing Address - Country:US
Mailing Address - Phone:541-500-1779
Mailing Address - Fax:541-500-1943
Practice Address - Street 1:2627 SISKIYOU BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8188
Practice Address - Country:US
Practice Address - Phone:541-500-1779
Practice Address - Fax:541-500-1943
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORJ284217OtherPACIFIC SOURCE
OR804894012OtherBLUE CROSS
OR804894012OtherBLUE CROSS