Healthcare Provider Details

I. General information

NPI: 1568409779
Provider Name (Legal Business Name): SANDRA DENISE MARTIN O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 KIMEL PARK DR
WINSTON-SALEM NC
27103-6946
US

IV. Provider business mailing address

PO BOX 25626
WINSTON-SALEM NC
27114-5626
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-1270
  • Fax: 336-765-6375
Mailing address:
  • Phone: 336-768-1270
  • Fax: 336-765-6375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6010
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: