Provider Demographics
NPI:1609850890
Name:MARTIN, GLENN T (AUD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:T
Last Name:MARTIN
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3692 E SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-7237
Mailing Address - Country:US
Mailing Address - Phone:702-735-7668
Mailing Address - Fax:702-735-1411
Practice Address - Street 1:3692 E SUNSET RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-7237
Practice Address - Country:US
Practice Address - Phone:702-735-7668
Practice Address - Fax:702-735-1411
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV262231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1609850890Medicaid
NV100501339Medicaid