Basic Information
| Provider Information | |||||||||
| NPI: | 1629234877 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DOE | ||||||||
| FirstName: | MARTA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.A. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1608 W PLATH AVE | ||||||||
| Address2: | #2 | ||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989025249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099456005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5001 STATESMAN DR | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750632414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772825613 | ||||||||
| FaxNumber: | 8775081628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
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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 | LL60025574 | WA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 7980709 | 05 | WA | MEDICAID | 506506 | 01 | WA | MEDICARE SPEECH | OTHER |