MEDICARE: AQUESHA MARTIN MS, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	OT003614	GA

General Provider Information

NPI Number	:	1437248663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AQUESHA MARTIN MS, OTR/L

Provider Business Mailing Address
First Line	:	1799 MISSION PARK CT
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-7511
Country	:	US
Telephone Number	:	678-794-2445
Fax Number	:	770-979-2591

Provider Business Practice Location Address
First Line	:	1799 MISSION PARK CT
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-7511
Country	:	US
Telephone Number	:	678-794-2445
Fax Number	:	770-979-2591

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/09/2007

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