Provider Demographics
NPI:1912043332
Name:O'BRYAN, MARTHA MARIN (MS)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:MARIN
Last Name:O'BRYAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 W WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-1312
Mailing Address - Country:US
Mailing Address - Phone:602-589-1001
Mailing Address - Fax:602-589-0140
Practice Address - Street 1:4510 N 37TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-3206
Practice Address - Country:US
Practice Address - Phone:602-336-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0719235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLP0719OtherSTATE LICENSE-SLP