Provider Demographics
NPI:1912746496
Name:MARTIN, TAYLA GRACE CLARK
Entity type:Individual
Prefix:
First Name:TAYLA
Middle Name:GRACE CLARK
Last Name:MARTIN
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:TAYLA
Other - Middle Name:GRACE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:507 LAMONT STREET APT 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604
Mailing Address - Country:US
Mailing Address - Phone:423-946-8771
Mailing Address - Fax:
Practice Address - Street 1:17507 LEE HWY
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210
Practice Address - Country:US
Practice Address - Phone:276-525-1338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204001374235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist