Healthcare Provider Details

I. General information

NPI: 1245149665
Provider Name (Legal Business Name): WILL MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 NE 5TH AVE
GRAND RAPIDS MN
55744-2963
US

IV. Provider business mailing address

822 NE 5TH AVE
GRAND RAPIDS MN
55744-2963
US

V. Phone/Fax

Practice location:
  • Phone: 218-327-5739
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1052906
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: