Provider Demographics
NPI:1700203635
Name:SLATER, MARTHA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:
Last Name:SLATER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 LOWRY ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62363-1768
Mailing Address - Country:US
Mailing Address - Phone:217-285-5200
Mailing Address - Fax:217-285-5212
Practice Address - Street 1:610 LOWRY ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:IL
Practice Address - Zip Code:62363-1768
Practice Address - Country:US
Practice Address - Phone:217-285-5200
Practice Address - Fax:217-285-5212
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160001626225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant