Provider Demographics
NPI:1689600645
Name:MARTIN, TERI (SLP)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PINE TREE LOOP
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8313
Mailing Address - Country:US
Mailing Address - Phone:501-812-4809
Mailing Address - Fax:
Practice Address - Street 1:304 SORENSON ST
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72118-3473
Practice Address - Country:US
Practice Address - Phone:501-246-5191
Practice Address - Fax:501-246-5393
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1538235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y432OtherBLUE CROSS BLUE SHIELD
AR142829721Medicaid