Provider Demographics
NPI:1942781778
Name:MARTIN, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MARTIN
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 1:152 PORTERS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COLORA
Mailing Address - State:MD
Mailing Address - Zip Code:21917-1037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:152 PORTERS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:COLORA
Practice Address - State:MD
Practice Address - Zip Code:21917-1037
Practice Address - Country:US
Practice Address - Phone:443-945-6323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty