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General NPI Number Information
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NPI Number | 1891981593
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Entity Type | Individual
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Provider Name | ANGIE RACHELLE MARTY LADC
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Gender | Female
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Dates
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Enumeration Date | 09/18/2007
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Last Update Date | 09/03/2022
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Provider Practice Location Address
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Address Line | 6017 BIRCHWOOD RD
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City | WOODBURY
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State | MN
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Zip | 55125-2007
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Country | US
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Telephone | 651-354-5455
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Fax |
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Provider Business Mailing Address
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Address Line | 3817 PRAIRIE RD
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City | WHITE BEAR LAKE
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State | MN
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Zip | 55110-4837
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Country | US
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Telephone |
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Fax |
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 304564
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License Number State | MN
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