Provider Demographics
NPI:1699143784
Name:MARTIN, STACY (PTA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
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 1:300 STRODE AVE
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-2874
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 STRODE AVE
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-2874
Practice Address - Country:US
Practice Address - Phone:717-917-8785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI000617225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant