Provider Demographics
NPI:1417565532
Name:MARTIN, CHARLENE SAMONE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:SAMONE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:SAMONE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS CCC-SLP
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:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007542235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP007542OtherGEORGIA LICENSING ENTITY
GASLP007542OtherSTATE LICENSURE SPEECH LANGUAGE PATHOLOGY
GA10005249OtherAMERICAN SPEECH AND HEARING ASSOCIATION