Provider Demographics
NPI:1063764074
Name:FUGATE, MARTHA J
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:J
Last Name:FUGATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 CORONETTE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-4537
Mailing Address - Country:US
Mailing Address - Phone:937-331-8983
Mailing Address - Fax:937-771-5422
Practice Address - Street 1:600 W NATIONAL RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1469
Practice Address - Country:US
Practice Address - Phone:937-836-3149
Practice Address - Fax:937-771-5422
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03403224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant