Provider Demographics
NPI:1386484236
Name:MARTIN, PETER (MSED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MSED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13132 SE RAMONA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4113
Mailing Address - Country:US
Mailing Address - Phone:503-256-6531
Mailing Address - Fax:
Practice Address - Street 1:13132 SE RAMONA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-4113
Practice Address - Country:US
Practice Address - Phone:503-256-6531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR015719235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist