Provider Demographics
NPI:1780775627
Name:MARTIN, RENEE DIEZ (PT)
Entity type:Individual
Prefix:MS
First Name:RENEE
Middle Name:DIEZ
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:RENEE
Other - Middle Name:KIPLYN
Other - Last Name:DIEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1014 WEST ST. CLARE BLVD
Mailing Address - Street 2:SUITE 1050
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737
Mailing Address - Country:US
Mailing Address - Phone:225-743-2060
Mailing Address - Fax:225-743-2065
Practice Address - Street 1:1014 WEST ST. CLARE BLVD
Practice Address - Street 2:SUITE 1050
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737
Practice Address - Country:US
Practice Address - Phone:225-743-2060
Practice Address - Fax:225-743-2065
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist