Provider Demographics
NPI:1366217275
Name:MARTIN, MANDI JO
Entity type:Individual
Prefix:
First Name:MANDI
Middle Name:JO
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:CIRCLE
Mailing Address - State:MT
Mailing Address - Zip Code:59215-0449
Mailing Address - Country:US
Mailing Address - Phone:406-650-2027
Mailing Address - Fax:
Practice Address - Street 1:311 MAIN ST
Practice Address - Street 2:
Practice Address - City:CIRCLE
Practice Address - State:MT
Practice Address - Zip Code:59215-7516
Practice Address - Country:US
Practice Address - Phone:406-650-2027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT16029225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist