1528058591 NPI number — MS. SHEWAN MICHELLE MARTIN MS, CCC-SLP

Table of content: MS. SHEWAN MICHELLE MARTIN MS, CCC-SLP (NPI 1528058591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528058591 NPI number — MS. SHEWAN MICHELLE MARTIN MS, CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
SHEWAN
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528058591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
01/11/2016
NPI Reactivation Date:
03/01/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 516
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAFFORD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22555-0516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-454-2021
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4445 CORPORATION LANE
Provider Second Line Business Practice Location Address:
SUITE 264
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23462-6584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-454-2021
Provider Business Practice Location Address Fax Number:
410-224-7637
Provider Enumeration Date:
10/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  04257 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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