Provider Demographics
NPI:1952565152
Name:MARTIN, VANDY (LMT)
Entity Type:Individual
Prefix:MS
First Name:VANDY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 S 2ND ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-1840
Mailing Address - Country:US
Mailing Address - Phone:808-854-5775
Mailing Address - Fax:
Practice Address - Street 1:3487 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-5674
Practice Address - Country:US
Practice Address - Phone:406-721-9080
Practice Address - Fax:406-721-9008
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-5993225700000X
HIMAT 4688225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist