Provider Demographics
NPI:1902979610
Name:MARTINEZ, SUSANNAH ELIZABETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:ELIZABETH
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:SUSANNAH
Other - Middle Name:ELIZABETH
Other - Last Name:SCHMICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:175 UNION ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6100
Mailing Address - Country:US
Mailing Address - Phone:207-941-2850
Mailing Address - Fax:208-941-2852
Practice Address - Street 1:175 UNION ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6100
Practice Address - Country:US
Practice Address - Phone:207-941-2850
Practice Address - Fax:208-941-2852
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1776235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432335699Medicaid
ME432335699Medicaid