Provider Demographics
NPI:1386976710
Name:MARTIN, THERESA ANN (DC)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 PONCE DELEON BLVD
Mailing Address - Street 2:601B
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-1031
Mailing Address - Country:US
Mailing Address - Phone:727-400-4807
Mailing Address - Fax:727-400-4809
Practice Address - Street 1:1180 PONCE DELEON BLVD
Practice Address - Street 2:601B
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-1031
Practice Address - Country:US
Practice Address - Phone:727-400-4807
Practice Address - Fax:727-400-4809
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9721111N00000X
CADC31944111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor