Provider Demographics
NPI:1225588635
Name:MARTINEZ, AUDRA (LMT, CMMP)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LMT, CMMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16033 E 96TH WAY
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-9100
Mailing Address - Country:US
Mailing Address - Phone:303-919-4104
Mailing Address - Fax:
Practice Address - Street 1:11325 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80233-2601
Practice Address - Country:US
Practice Address - Phone:303-457-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO799225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO799OtherDORA: LICENSED MASSAGE THERAPIST