Provider Demographics
NPI:1922432707
Name:DANIEL, MARTHA MACKENZIE (M ED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:MACKENZIE
Last Name:DANIEL
Suffix:
Gender:F
Credentials:M ED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 EZEKIEL WAY
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-2196
Mailing Address - Country:US
Mailing Address - Phone:770-584-9638
Mailing Address - Fax:
Practice Address - Street 1:1305 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-9116
Practice Address - Country:US
Practice Address - Phone:770-584-9638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET001953235Z00000X
GASLP008730235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist