Provider Demographics
NPI:1245730241
Name:MARTIN, MANDI MARIE (AT)
Entity type:Individual
Prefix:
First Name:MANDI
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 MERCY DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-2614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 SCHNEIDER ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-3349
Practice Address - Country:US
Practice Address - Phone:330-491-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0048692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer