Provider Demographics
NPI:1104116003
Name:MARTIN, BECKY JOANN (PTA)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:JOANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SAN CARLOS RD APT 310
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2665
Mailing Address - Country:US
Mailing Address - Phone:719-564-2370
Mailing Address - Fax:
Practice Address - Street 1:100 SAN CARLOS RD APT 310
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2665
Practice Address - Country:US
Practice Address - Phone:719-564-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO311679605261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0012683OtherCOLORADO PTA-C