Provider Demographics
NPI:1508031915
Name:MARTIN, TRACY LYNNE (LPTA)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LYNNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 BLUE RIDGE VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-4380
Mailing Address - Country:US
Mailing Address - Phone:434-384-9646
Mailing Address - Fax:
Practice Address - Street 1:701 W MAIN BLVD
Practice Address - Street 2:
Practice Address - City:CHURCH HILL
Practice Address - State:TN
Practice Address - Zip Code:37642-3915
Practice Address - Country:US
Practice Address - Phone:423-357-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4297225200000X
VA2306602365225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant