Provider Demographics
NPI:1447578794
Name:KING, MARTHA MCRACKEN
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:MCRACKEN
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARTHA
Other - Middle Name:ISABEL
Other - Last Name:MCRACKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:611 MAGELLAN DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-1008
Mailing Address - Country:US
Mailing Address - Phone:941-465-7133
Mailing Address - Fax:866-701-1969
Practice Address - Street 1:611 MAGELLAN DR
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-1008
Practice Address - Country:US
Practice Address - Phone:941-465-7133
Practice Address - Fax:866-701-1969
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002345500Medicaid