Provider Demographics
NPI:1508100231
Name:MARTIN, SHANAZ (PT, LNHA)
Entity Type:Individual
Prefix:MRS
First Name:SHANAZ
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT, LNHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 LORRIE LN
Mailing Address - Street 2:
Mailing Address - City:WANAQUE
Mailing Address - State:NJ
Mailing Address - Zip Code:07465-1104
Mailing Address - Country:US
Mailing Address - Phone:973-986-3014
Mailing Address - Fax:201-848-4259
Practice Address - Street 1:301 SICOMAC AVE
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-2159
Practice Address - Country:US
Practice Address - Phone:201-848-4323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01143300225100000X
NY022493-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist