Healthcare Provider Details

I. General information

NPI: 1124728092
Provider Name (Legal Business Name): LAMARTHA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARTHA MARTIN

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14605 POTOMAC BRANCH DR STE 300
WOODBRIDGE VA
22191-3337
US

IV. Provider business mailing address

1841 RIVER HERITAGE BLVD
DUMFRIES VA
22026-2822
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-1112
  • Fax:
Mailing address:
  • Phone: 703-785-1237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: