Provider Demographics
NPI:1700652252
Name:MARTIN BECERRA, RAQUEL V
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:V
Last Name:MARTIN BECERRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1949 HIGHWAY 81 STE 100
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-4583
Mailing Address - Country:US
Mailing Address - Phone:770-207-6390
Mailing Address - Fax:
Practice Address - Street 1:1949 HIGHWAY 81 STE 100
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4583
Practice Address - Country:US
Practice Address - Phone:770-207-6390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP012726235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist