Provider Demographics
NPI:1063900710
Name:MARTINO, KATELYN VICTORIA (CCC-MED SLP)
Entity type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:VICTORIA
Last Name:MARTINO
Suffix:
Gender:F
Credentials:CCC-MED SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1901
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30077-1901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 ACADEMY ST STE 102
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-3008
Practice Address - Country:US
Practice Address - Phone:404-444-1521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010025235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist