Provider Demographics
NPI:1255811816
Name:MARTIN, CALISSA
Entity type:Individual
Prefix:
First Name:CALISSA
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 1:292 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-2206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:855 STAHLHEBER RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-1963
Practice Address - Country:US
Practice Address - Phone:513-844-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2119099225200000X
OH10070225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2119099OtherPHYSICAL THERAPY ASSISTANT LICENSE
OH10070OtherPHYSICAL THERAPIST ASSISTANT LICENSE