Provider Demographics
NPI:1851668628
Name:MARTINO, JODY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:MARTINO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-1213
Mailing Address - Country:US
Mailing Address - Phone:518-793-9375
Mailing Address - Fax:
Practice Address - Street 1:11 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1213
Practice Address - Country:US
Practice Address - Phone:518-793-9375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012391-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist