Provider Demographics
NPI:1467480095
Name:MARTIN, MARY DAVISSON (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DAVISSON
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 BAL HARBOUR DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-5377
Mailing Address - Country:US
Mailing Address - Phone:636-343-6279
Mailing Address - Fax:636-343-6279
Practice Address - Street 1:1700B GILSINN LN
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2004
Practice Address - Country:US
Practice Address - Phone:636-343-6279
Practice Address - Fax:636-343-6279
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000025519Medicare PIN