Provider Demographics
NPI:1467709022
Name:MARTIN, LARA (PT)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
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 1:77 NORTH AIRLITE STREET
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 NORTH AIRLITE STREET
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123
Practice Address - Country:US
Practice Address - Phone:847-695-5904
Practice Address - Fax:847-695-5985
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012297225100000X, 2251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist