Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 070012297 | IL |
Y | 2251N0400X | Physical Therapist - Neurology | 070012297 | IL |
NPI | 1467709022 |
---|---|
Provider Name | Lara Martin |
First Address | Elgin, IL 60123 |
Second Address | Elgin, IL 60123 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2012 |
Last Update Date | 13/08/2012 |