Provider Demographics
NPI:1013152495
Name:MARTIN, WILSON BRUCE (CF/SLP)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:BRUCE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CF/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18740 COUNTY ROAD V
Mailing Address - Street 2:
Mailing Address - City:LEWIS
Mailing Address - State:CO
Mailing Address - Zip Code:81327-9610
Mailing Address - Country:US
Mailing Address - Phone:970-882-3186
Mailing Address - Fax:
Practice Address - Street 1:18740 COUNTY ROAD V
Practice Address - Street 2:
Practice Address - City:LEWIS
Practice Address - State:CO
Practice Address - Zip Code:81327-9610
Practice Address - Country:US
Practice Address - Phone:970-882-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPENDING235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist