Provider Demographics
NPI:1811162613
Name:LOCKETT, MARTHA LEIGH (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:LEIGH
Last Name:LOCKETT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:LEIGH
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:6957 HIGHWAY 10 NW
Mailing Address - Street 2:SUITE #102
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303
Mailing Address - Country:US
Mailing Address - Phone:763-427-2210
Mailing Address - Fax:
Practice Address - Street 1:6957 HIGHWAY 10 NW
Practice Address - Street 2:SUITE #102
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303
Practice Address - Country:US
Practice Address - Phone:763-427-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1171235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR133817721Medicaid