MEDICARE: KATHRYN BROOKE MARTIN 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	2202006651	VA

General Provider Information

NPI Number	:	1992139604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHRYN BROOKE MARTIN CCC-SLP

Provider Business Mailing Address
First Line	:	46 DIAMOND DR
Second Line	:
City	:	NORTH DINWIDDIE
State	:	VA
Zip	:	23803-7495
Country	:	US
Telephone Number	:	804-518-0780
Fax Number	:	804-518-0787

Provider Business Practice Location Address
First Line	:	46 DIAMOND DR
Second Line	:
City	:	NORTH DINWIDDIE
State	:	VA
Zip	:	23803-7495
Country	:	US
Telephone Number	:	804-518-0780
Fax Number	:	804-518-0787

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

Provider Enumeration Date	:	08/29/2013
Last Update Date	:	02/23/2018

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Directions to “ KATHRYN BROOKE MARTIN CCC-SLP” Practice Location

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