Provider Demographics
NPI:1437302627
Name:MARTIN, KATRINA MACKENZIE (MS-CCL/SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:MACKENZIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS-CCL/SLP
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:MARIE
Other - Last Name:MACKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:149 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1434
Mailing Address - Country:US
Mailing Address - Phone:585-377-2230
Mailing Address - Fax:585-377-2312
Practice Address - Street 1:149 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1434
Practice Address - Country:US
Practice Address - Phone:585-377-2230
Practice Address - Fax:585-377-2312
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017450-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2468KAMedicaid