Provider Demographics
NPI:1619207438
Name:VILLWOCK, MARTHA LEMUS-MEDINA (MA, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:LEMUS-MEDINA
Last Name:VILLWOCK
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 888193
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30356-0193
Mailing Address - Country:US
Mailing Address - Phone:770-901-9949
Mailing Address - Fax:770-901-9932
Practice Address - Street 1:4243 DUNWOODY CLUB DR
Practice Address - Street 2:SUITE 104
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-5206
Practice Address - Country:US
Practice Address - Phone:770-901-9949
Practice Address - Fax:770-901-9932
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005361235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist