Provider Demographics
NPI:1538376363
Name:GLENN, MARTA CAMPBELL (LMP)
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:CAMPBELL
Last Name:GLENN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 143RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-9604
Mailing Address - Country:US
Mailing Address - Phone:360-943-3399
Mailing Address - Fax:360-943-3399
Practice Address - Street 1:1702 4TH AVE E
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4534
Practice Address - Country:US
Practice Address - Phone:360-357-5330
Practice Address - Fax:360-943-3399
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00008002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist