Provider Demographics
NPI:1952867640
Name:FAY, MARTHA BANKS (MED)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:BANKS
Last Name:FAY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 TALMADGE DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2746
Mailing Address - Country:US
Mailing Address - Phone:706-593-7526
Mailing Address - Fax:
Practice Address - Street 1:1305 JENNINGS MILL RD
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7238
Practice Address - Country:US
Practice Address - Phone:706-552-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010210235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003216567AMedicaid