Provider Demographics
NPI:1427180355
Name:WENDEROTH, MARTHA C (SLP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:C
Last Name:WENDEROTH
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 1:440 JEFFERSON ST NE
Mailing Address - Street 2:ZIA ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1235
Mailing Address - Country:US
Mailing Address - Phone:505-255-7451
Mailing Address - Fax:
Practice Address - Street 1:440 JEFFERSON ST NE
Practice Address - Street 2:ZIA ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1235
Practice Address - Country:US
Practice Address - Phone:505-255-7451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1601235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML 6056Medicaid