Healthcare Provider Details

I. General information

NPI: 1104253368
Provider Name (Legal Business Name): CLARA JANE MARTIN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ALLAWOOD CT STE 110
SIMPSONVILLE SC
29681-6207
US

IV. Provider business mailing address

121 TALL PINES RD
FOUNTAIN INN SC
29644-9712
US

V. Phone/Fax

Practice location:
  • Phone: 864-238-9333
  • Fax:
Mailing address:
  • Phone: 864-238-9333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3457
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1540
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: