Provider Demographics
NPI:1518292341
Name:MARTIN, ELIZABETH AMANDA (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:AMANDA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:AMANDA
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:15271 BAILEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34614-2916
Mailing Address - Country:US
Mailing Address - Phone:469-236-2484
Mailing Address - Fax:
Practice Address - Street 1:15271 BAILEY HILL RD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34614-2916
Practice Address - Country:US
Practice Address - Phone:469-236-2484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1196SP235Z00000X
MTSLP1196235Z00000X
FLSA21060235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist