Provider Demographics
NPI:1457684276
Name:MARTIN, SHELLY (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:M
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:4668 PEMBROKE BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6423
Mailing Address - Country:US
Mailing Address - Phone:757-648-8562
Mailing Address - Fax:757-648-8564
Practice Address - Street 1:4668 PEMBROKE BLVD STE 115
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6423
Practice Address - Country:US
Practice Address - Phone:757-648-8562
Practice Address - Fax:757-648-8564
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06103235Z00000X
VA2202009088235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist