Provider Demographics
NPI:1861851990
Name:MARTINO, GINA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MARTINO
Suffix:
Gender:F
Credentials: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:N71W23516 HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-3285
Mailing Address - Country:US
Mailing Address - Phone:510-579-2301
Mailing Address - Fax:
Practice Address - Street 1:N71W23516 HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-3285
Practice Address - Country:US
Practice Address - Phone:510-579-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4236235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist