Provider Demographics
NPI:1578307419
Name:MARTIN, AMBER LEIGH (LCOTA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:LEIGH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCOTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 STUBBS AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5629
Mailing Address - Country:US
Mailing Address - Phone:318-388-8414
Mailing Address - Fax:318-388-8558
Practice Address - Street 1:1603 GOODWIN RD
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2907
Practice Address - Country:US
Practice Address - Phone:318-255-7550
Practice Address - Fax:318-255-7552
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA322158224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty