Provider Demographics
NPI:1992139604
Name:MARTIN, KATHRYN BROOKE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:BROOKE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:NORTH DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23803-7495
Mailing Address - Country:US
Mailing Address - Phone:804-518-0780
Mailing Address - Fax:804-518-0787
Practice Address - Street 1:46 DIAMOND DR
Practice Address - Street 2:
Practice Address - City:NORTH DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23803-7495
Practice Address - Country:US
Practice Address - Phone:804-518-0780
Practice Address - Fax:804-518-0787
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006651235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist