Healthcare Provider Details

I. General information

NPI: 1164783684
Provider Name (Legal Business Name): GWEN MARIE MARTIN LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 05/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HOSPITAL DR
CRESTVIEW FL
32539-7355
US

IV. Provider business mailing address

500 HOSPITAL DR
CRESTVIEW FL
32539-7355
US

V. Phone/Fax

Practice location:
  • Phone: 850-398-6428
  • Fax: 850-398-6507
Mailing address:
  • Phone: 850-398-6428
  • Fax: 850-398-6507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA21573
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1486
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: