Provider Demographics
NPI:1457013922
Name:MARTIN, CHARLOTTE MARIE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:
Other - Last Name:MREKVICSKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5095 HAMMOCK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-8570
Mailing Address - Country:US
Mailing Address - Phone:615-772-7072
Mailing Address - Fax:
Practice Address - Street 1:3731 W COOK RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9662
Practice Address - Country:US
Practice Address - Phone:317-204-3736
Practice Address - Fax:317-449-5783
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist