Basic Information
| Provider Information | |||||||||
| NPI: | 1629391529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUHIG | ||||||||
| OtherFirstName: | ANN | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1111 TRINITY LN STE 111 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617048112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096636461 | ||||||||
| FaxNumber: | 3096618107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 TRINITY LN STE 111 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617048112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096636461 | ||||||||
| FaxNumber: | 3096618107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2010 | ||||||||
| LastUpdateDate: | 03/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 07016889 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.