Provider Demographics
NPI:1356920821
Name:MARTIN, CHRISTINE LAVELY (MA CCC/SLP)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LAVELY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 PONDELLA RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-3500
Mailing Address - Country:US
Mailing Address - Phone:352-270-4756
Mailing Address - Fax:
Practice Address - Street 1:991 PONDELLA RD
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-3500
Practice Address - Country:US
Practice Address - Phone:352-270-4756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-03
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7076235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty