Provider Demographics
NPI:1104974898
Name:BLENKO, MARTHA NEALE (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:NEALE
Last Name:BLENKO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-1332
Mailing Address - Country:US
Mailing Address - Phone:304-743-8778
Mailing Address - Fax:
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3800
Practice Address - Country:US
Practice Address - Phone:304-526-6335
Practice Address - Fax:304-526-4866
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0117235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0152541000Medicaid