Provider Demographics
NPI:1629675871
Name:MARTIN, LORIBETH RIDENOUR (MS L-PTA)
Entity Type:Individual
Prefix:
First Name:LORIBETH
Middle Name:RIDENOUR
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS L-PTA
Other - Prefix:
Other - First Name:LORIBETH
Other - Middle Name:RIDENOUR
Other - Last Name:DOMINIQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:113 STOUFFER AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6613
Mailing Address - Country:US
Mailing Address - Phone:301-739-0418
Mailing Address - Fax:
Practice Address - Street 1:400 CLOCKTOWER RIDGE DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22603-3878
Practice Address - Country:US
Practice Address - Phone:540-431-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWVPTA002672225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant