Provider Demographics
NPI:1518134089
Name:PROFESSIONAL HEARING SOLUTIONS, INC
Entity Type:Organization
Organization Name:PROFESSIONAL HEARING SOLUTIONS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINO
Authorized Official - Suffix:
Authorized Official - Credentials:AUDIOLOGIST
Authorized Official - Phone:719-671-6674
Mailing Address - Street 1:184 S TIFFANY DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-3583
Mailing Address - Country:US
Mailing Address - Phone:719-671-6674
Mailing Address - Fax:719-647-0262
Practice Address - Street 1:184 S TIFFANY DR
Practice Address - Street 2:SUITE 108
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-3583
Practice Address - Country:US
Practice Address - Phone:719-671-6674
Practice Address - Fax:719-647-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16OtherCO STATE LICENSE
CO14634864Medicaid
CO16OtherCO STATE LICENSE