Provider Demographics
NPI:1568669885
Name:MARTIN, LISA ANN
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 LOS ARBOLES DR
Mailing Address - Street 2:
Mailing Address - City:WOLVERINE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2028
Mailing Address - Country:US
Mailing Address - Phone:248-669-9876
Mailing Address - Fax:
Practice Address - Street 1:55 W POND DR
Practice Address - Street 2:SUITE 4
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390
Practice Address - Country:US
Practice Address - Phone:248-668-9355
Practice Address - Fax:248-668-9351
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236629Medicare ID - Type Unspecified