MEDICARE: MARTHA HAINEY FLACKE MA 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	003395	NY

General Provider Information

NPI Number	:	1427334689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA HAINEY FLACKE MA CCC-SLP

Provider Business Mailing Address
First Line	:	1153 BURGOYNE AVE SUITE 2
Second Line	:	WSWHE BOCES
City	:	FORT EDWARD
State	:	NY
Zip	:	12828-1134
Country	:	US
Telephone Number	:	518-581-3605
Fax Number	:	518-746-3629

Provider Business Practice Location Address
First Line	:	1153 BURGOYNE AVE SUITE 2
Second Line	:	WSWHE BOCES
City	:	FORT EDWARD
State	:	NY
Zip	:	12828-1134
Country	:	US
Telephone Number	:	518-581-3605
Fax Number	:	518-746-3629

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

Provider Enumeration Date	:	11/01/2011
Last Update Date	:	11/01/2011

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