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General NPI Number Information
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NPI Number | 1861710659
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Entity Type | Individual
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Provider Name | MARTHA MARY CLEMENTS PT
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Gender | Female
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Dates
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Enumeration Date | 05/04/2010
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Last Update Date | 05/04/2010
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Provider Practice Location Address
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Address Line | 511 E 4TH ST
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City | SHOSHONE
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State | ID
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Zip | 83352-5380
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Country | US
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Telephone | 208-886-2549
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Fax | 208-886-2228
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Provider Business Mailing Address
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Address Line | 25117 SW PARKWAY AVE SUITE D
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City | WILSONVILLE
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State | OR
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Zip | 97070-9697
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Country | US
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Telephone | 888-757-3422
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Fax | 877-282-1880
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT-2633
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License Number State | ID
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