Healthcare Provider Details

I. General information

NPI: 1770664815
Provider Name (Legal Business Name): TRACI KRISTINE MARTIN MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACI KRISTINE GAMBLIN MS CCC-SLP

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 OLD HOWELL RD
GREENVILLE SC
29615-1969
US

IV. Provider business mailing address

2202 FALCON CREEK DR
FRANKLIN TN
37067-4098
US

V. Phone/Fax

Practice location:
  • Phone: 877-508-3237
  • Fax:
Mailing address:
  • Phone: 720-545-8160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146008086
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4963
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: