Provider Demographics
NPI:1417101106
Name:MARTIN, LAURIE (MHSC CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MHSC CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 BALLINA CANYON RD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4109
Mailing Address - Country:US
Mailing Address - Phone:310-488-8960
Mailing Address - Fax:
Practice Address - Street 1:3623 BALLINA CANYON RD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4109
Practice Address - Country:US
Practice Address - Phone:310-488-8960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-09
Last Update Date:2008-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15974235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist