Provider Demographics
NPI:1346301165
Name:MARTONICK, COLLEEN (MSOTR/L, CLT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MARTONICK
Suffix:
Gender:F
Credentials:MSOTR/L, CLT
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:DARROUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:405 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8628
Mailing Address - Country:US
Mailing Address - Phone:321-327-8509
Mailing Address - Fax:321-327-2130
Practice Address - Street 1:405 N WICKHAM RD STE 103
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935
Practice Address - Country:US
Practice Address - Phone:321-327-8509
Practice Address - Fax:321-327-2130
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC-008065225X00000X
FLOT18735225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
814251OtherFIRST PRIORITY
393533OtherHEALTH AMERICA ASSURANCE
814187OtherFIRST PRIORITY
1447433OtherBLUE SHIELD
388447OtherHEALTH AMERICA ASSURANCE
818055OtherFIRST PRIORITY
FLOT18735OtherDOH
393534OtherHEALTH AMERICA ASSURANCE