Provider Demographics
NPI:1376209353
Name:MARTINEZ, MIA (DPT)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1926
Mailing Address - Country:US
Mailing Address - Phone:860-409-4595
Mailing Address - Fax:
Practice Address - Street 1:134 MAIN STREET EXT STE 100
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3813
Practice Address - Country:US
Practice Address - Phone:860-740-3087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-13
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist