Provider Demographics
NPI:1477674760
Name:MARTIN, WILLIAM BRADLEY (MA CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:BRADLEY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9037
Mailing Address - Country:US
Mailing Address - Phone:505-599-8535
Mailing Address - Fax:505-599-8536
Practice Address - Street 1:1390 E 20TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9037
Practice Address - Country:US
Practice Address - Phone:505-599-8535
Practice Address - Fax:505-599-8536
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1425235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK2563Medicaid