Provider Demographics
NPI:1508295221
Name:MARTIN, LISA MARY (PTA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARY
Last Name:MARTIN
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 1:32 BUENA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-4660
Mailing Address - Country:US
Mailing Address - Phone:302-328-2580
Mailing Address - Fax:
Practice Address - Street 1:32 BUENA VISTA DR
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-4660
Practice Address - Country:US
Practice Address - Phone:302-328-2580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000338320700000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities