Basic Information
| Provider Information | |||||||||
| NPI: | 1861644478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.A., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 HIDDEN VALLEY DRIVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473745155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652776466 | ||||||||
| FaxNumber: | 8667854924 | ||||||||
| Practice Location | |||||||||
| Address1: | 1752 LLANFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452242961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652776466 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2008 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 22003806A | IN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 12007679 | 01 | ASHA | OTHER |