Provider Demographics
NPI:1588869804
Name:MARTIN, LISA ANNE (ATC, CSCS)
Entity type:Individual
Prefix:MISS
First Name:LISA
Middle Name:ANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8640 INGALLS LN
Mailing Address - Street 2:
Mailing Address - City:CAMBY
Mailing Address - State:IN
Mailing Address - Zip Code:46113-8116
Mailing Address - Country:US
Mailing Address - Phone:317-821-1668
Mailing Address - Fax:
Practice Address - Street 1:8227 NORTHWEST BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1387
Practice Address - Country:US
Practice Address - Phone:317-415-5747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000417A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer