Provider Demographics
NPI:1205501814
Name:MARTIN, CASSANDRA (SLP)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 COOPER AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-1512
Mailing Address - Country:US
Mailing Address - Phone:701-352-2574
Mailing Address - Fax:
Practice Address - Street 1:300 BOOTH AVE
Practice Address - Street 2:
Practice Address - City:LARIMORE
Practice Address - State:ND
Practice Address - Zip Code:58251-4410
Practice Address - Country:US
Practice Address - Phone:701-343-2249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1875235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1975Medicaid