MEDICARE: ELIZABETH MARTIN MS, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	TSLP9096	AZ

General Provider Information

NPI Number	:	1215330907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH MARTIN MS, CCC-SLP

Provider Business Mailing Address
First Line	:	3721 ORION DR
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91941-8027
Country	:	US
Telephone Number	:	802-505-5963
Fax Number	:

Provider Business Practice Location Address
First Line	:	3721 ORION DR
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91941-8027
Country	:	US
Telephone Number	:	802-505-5963
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2014
Last Update Date	:	04/13/2021

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