Provider Demographics
NPI:1598889032
Name:MARTIN, AMY J
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:J
Other - Last Name:POLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2478 COUNTY ROAD 2320
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270
Mailing Address - Country:US
Mailing Address - Phone:660-263-5979
Mailing Address - Fax:660-263-5179
Practice Address - Street 1:HIGBEE R-VIII
Practice Address - Street 2:101 EVANS
Practice Address - City:HIGBEE
Practice Address - State:MO
Practice Address - Zip Code:65257-0128
Practice Address - Country:US
Practice Address - Phone:660-263-5979
Practice Address - Fax:660-263-5179
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001000715225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO475302568Medicaid