Provider Demographics
NPI:1770664815
Name:MARTIN, TRACI KRISTINE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:KRISTINE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:KRISTINE
Other - Last Name:GAMBLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:2202 FALCON CREEK DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-4098
Mailing Address - Country:US
Mailing Address - Phone:720-545-8160
Mailing Address - Fax:
Practice Address - Street 1:536 OLD HOWELL RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-1969
Practice Address - Country:US
Practice Address - Phone:877-508-3237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008086235Z00000X
TN4963235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist