Healthcare Provider Details

I. General information

NPI: 1376803965
Provider Name (Legal Business Name): CHARLENE GAIL MARTENS M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E WILCOX DR
SIERRA VISTA AZ
85635-2526
US

IV. Provider business mailing address

7116 E LAGUNA AZUL AVE
MESA AZ
85209-4818
US

V. Phone/Fax

Practice location:
  • Phone: 520-459-8258
  • Fax:
Mailing address:
  • Phone: 310-339-4295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP8200
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: