Provider Demographics
NPI:1780965723
Name:MARTIN, CONSTANCE FAITH (PTA)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:FAITH
Last Name:MARTIN
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 1:102 EMERALD CT
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-7211
Mailing Address - Country:US
Mailing Address - Phone:478-957-1747
Mailing Address - Fax:
Practice Address - Street 1:405 OSIGIAN BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8958
Practice Address - Country:US
Practice Address - Phone:478-953-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-05
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002615225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant