Provider Demographics
NPI:1619694221
Name:MARTIN, RAVEN HANNAH (COTA)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:HANNAH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 ASH ST # 2
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:MA
Mailing Address - Zip Code:01562-2316
Mailing Address - Country:US
Mailing Address - Phone:386-295-6928
Mailing Address - Fax:
Practice Address - Street 1:2667 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8217
Practice Address - Country:US
Practice Address - Phone:321-329-0159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19172224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant