Healthcare Provider Details

I. General information

NPI: 1053141663
Provider Name (Legal Business Name): ELLIANA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIR STE 1575
SAINT CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIR STE 1575
SAINT CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-4922
  • Fax: 320-229-5183
Mailing address:
  • Phone: 320-229-4922
  • Fax: 320-229-5183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: