Provider Demographics
NPI:1306178264
Name:MARTIN, SUZANNE RUTH (PTA)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:RUTH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 DUANE AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:ME
Mailing Address - Zip Code:04861-3847
Mailing Address - Country:US
Mailing Address - Phone:207-542-0406
Mailing Address - Fax:
Practice Address - Street 1:12 DUANE AVE
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:ME
Practice Address - Zip Code:04861-3847
Practice Address - Country:US
Practice Address - Phone:207-542-0406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA70000924225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant