Provider Demographics
NPI:1982843876
Name:MARTIN, TERESA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 BLACK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-3139
Mailing Address - Country:US
Mailing Address - Phone:715-387-7885
Mailing Address - Fax:715-389-4071
Practice Address - Street 1:611 SAINT JOSEPH AVE
Practice Address - Street 2:REHAB SERVICES
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-1832
Practice Address - Country:US
Practice Address - Phone:715-387-7885
Practice Address - Fax:715-389-4071
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1545-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant