Provider Demographics
NPI:1255658357
Name:MARTIN, THEA ROCHELLE (LMT,)
Entity Type:Individual
Prefix:MS
First Name:THEA
Middle Name:ROCHELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMT,
Other - Prefix:MS
Other - First Name:SHELLY
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:206 KUYRKENDALL PL
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-3308
Mailing Address - Country:US
Mailing Address - Phone:228-323-1113
Mailing Address - Fax:
Practice Address - Street 1:206 KUYRKENDALL PL
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-3308
Practice Address - Country:US
Practice Address - Phone:228-323-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSLMT 1654225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist