Provider Demographics
NPI:1609606581
Name:MARTIN, LAVONDA GAYE (LMT)
Entity type:Individual
Prefix:MRS
First Name:LAVONDA
Middle Name:GAYE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 N HIGHWAY 96
Mailing Address - Street 2:
Mailing Address - City:CECIL
Mailing Address - State:AR
Mailing Address - Zip Code:72930-3049
Mailing Address - Country:US
Mailing Address - Phone:479-206-1573
Mailing Address - Fax:
Practice Address - Street 1:22 N GREENWOOD STREET
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:AR
Practice Address - Zip Code:72930
Practice Address - Country:US
Practice Address - Phone:479-207-0318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1616562225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist