Basic Information
| Provider Information | |||||||||
| NPI: | 1235480054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 315 | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391580315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012069195 | ||||||||
| FaxNumber: | 6019578391 | ||||||||
| Practice Location | |||||||||
| Address1: | 1260 OCEAN SPRINGS ROAD | ||||||||
| Address2: | THE GARDENS | ||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012069195 | ||||||||
| FaxNumber: | 3019578391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2012 | ||||||||
| LastUpdateDate: | 09/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | S0447 | MS | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 09014160 | 05 | MS | MEDICAID |