Provider Demographics
NPI:1114526811
Name:MARTIN MEDICAL SLP LLC
Entity Type:Organization
Organization Name:MARTIN MEDICAL SLP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:SAMONE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:404-556-7053
Mailing Address - Street 1:103 DUE WEST PASS
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-2545
Mailing Address - Country:US
Mailing Address - Phone:404-556-7053
Mailing Address - Fax:
Practice Address - Street 1:103 DUE WEST PASS
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-2545
Practice Address - Country:US
Practice Address - Phone:404-556-7053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10005249OtherNATIONAL AFFILIATION
GA1417565532OtherINDIVIDUAL NPI
GASLP007542OtherSTATE LICENSURE