Provider Demographics
NPI:1700129798
Name:SAM, MARTHA (PTA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 CLEVELAND AVE
Mailing Address - Street 2:SUITE 1 A
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3417
Mailing Address - Country:US
Mailing Address - Phone:678-361-7427
Mailing Address - Fax:
Practice Address - Street 1:1203 CLEVELAND AVE
Practice Address - Street 2:SUITE 1 A
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3417
Practice Address - Country:US
Practice Address - Phone:678-361-7427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)