Provider Demographics
NPI:1235480054
Name:MARTIN, DENISE M (SLP)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 315
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39158-0315
Mailing Address - Country:US
Mailing Address - Phone:601-206-9195
Mailing Address - Fax:601-957-8391
Practice Address - Street 1:1260 OCEAN SPRINGS ROAD
Practice Address - Street 2:THE GARDENS
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564
Practice Address - Country:US
Practice Address - Phone:601-206-9195
Practice Address - Fax:301-957-8391
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS0447235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014160Medicaid
MS09014160Medicaid