Provider Demographics
NPI:1396001335
Name:MARTIN, SALLY B (MS, CCC/SP)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:B
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, CCC/SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 SPRING SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-4604
Mailing Address - Country:US
Mailing Address - Phone:703-455-5611
Mailing Address - Fax:
Practice Address - Street 1:7143 SHREVE RD
Practice Address - Street 2:ACHIEVE BEYOND
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22043
Practice Address - Country:US
Practice Address - Phone:703-237-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202002028235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA235Z00000XMedicaid