Provider Demographics
NPI:1821572835
Name:PHOENIX, MARTIKA A
Entity Type:Individual
Prefix:
First Name:MARTIKA
Middle Name:A
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 NANCY LN
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-3011
Mailing Address - Country:US
Mailing Address - Phone:484-682-7788
Mailing Address - Fax:
Practice Address - Street 1:3925 NANCY LN
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-3011
Practice Address - Country:US
Practice Address - Phone:484-682-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOTA100000324224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty