Provider Demographics
NPI:1275606014
Name:CANNON-MEDCALF, MARTHA CHRISTINE (MED, CCC)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:CHRISTINE
Last Name:CANNON-MEDCALF
Suffix:
Gender:F
Credentials:MED, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 MANOR BROOK CT
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3062
Mailing Address - Country:US
Mailing Address - Phone:770-418-1778
Mailing Address - Fax:
Practice Address - Street 1:3483 SATELLITE BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8692
Practice Address - Country:US
Practice Address - Phone:770-418-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003411235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist