Basic Information
| Provider Information | |||||||||
| NPI: | 1144787110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | CARLYE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 VERANO ST | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383556921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014137578 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Practice Location | |||||||||
| Address1: | 2865 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HUMBOLDT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383433070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7317848405 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2019 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 3190 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.