Provider Demographics
NPI:1508136532
Name:LEPAGE-MARTINO, DENISE A (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:A
Last Name:LEPAGE-MARTINO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 FLORIDA PARK DR N
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8360
Mailing Address - Country:US
Mailing Address - Phone:904-460-3314
Mailing Address - Fax:
Practice Address - Street 1:3001 PALM COAST PKWY SE
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8209
Practice Address - Country:US
Practice Address - Phone:386-446-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21970225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant