Provider Demographics
NPI:1699239392
Name:MARTIN, OLIVIA ROBERTSON (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:ROBERTSON
Last Name:MARTIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 GALES AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3703
Mailing Address - Country:US
Mailing Address - Phone:704-526-5117
Mailing Address - Fax:
Practice Address - Street 1:1199 HAYES FOREST DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3377
Practice Address - Country:US
Practice Address - Phone:336-759-1044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-27
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12289225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist