Provider Demographics
NPI:1861752651
Name:MARTIN, DANIEL KRISTOFFER (LMT)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:KRISTOFFER
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 HOME AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3331
Mailing Address - Country:US
Mailing Address - Phone:708-990-6314
Mailing Address - Fax:
Practice Address - Street 1:1S132 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-3955
Practice Address - Country:US
Practice Address - Phone:630-705-1475
Practice Address - Fax:630-705-1566
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.010882225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist