Provider Demographics
NPI:1831497148
Name:MARTIN, BEULAH (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BEULAH
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12401 MIDSUMMER LN # B104
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-6703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12401 MIDSUMMER LN # B104
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-6703
Practice Address - Country:US
Practice Address - Phone:703-229-9481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004370235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist