Basic Information
| Provider Information | |||||||||
| NPI: | 1770664815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | KRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAMBLIN | ||||||||
| OtherFirstName: | TRACI | ||||||||
| OtherMiddleName: | KRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MS CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2202 FALCON CREEK DR | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370674098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205458160 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 536 OLD HOWELL RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296151969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8775083237 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 05/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146008086 | IL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 4963 | TN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.