Provider Demographics
NPI:1639672553
Name:MARTY, MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MARTY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 TANYARD TRCE
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-9735
Mailing Address - Country:US
Mailing Address - Phone:318-453-0387
Mailing Address - Fax:
Practice Address - Street 1:1400 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4620
Practice Address - Country:US
Practice Address - Phone:318-213-3810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist