Provider Demographics
NPI:1134279664
Name:MARTIN, CONSTANCE M (PHD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 N CICERO AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-2112
Mailing Address - Country:US
Mailing Address - Phone:312-458-9086
Mailing Address - Fax:847-983-4783
Practice Address - Street 1:7101 N CICERO AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-2112
Practice Address - Country:US
Practice Address - Phone:312-458-9086
Practice Address - Fax:847-983-4783
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005433103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical