Provider Demographics
NPI:1154828820
Name:MARTIN, DAVID LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 E HOPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61326-9616
Mailing Address - Country:US
Mailing Address - Phone:815-224-1610
Mailing Address - Fax:
Practice Address - Street 1:2960 CHARTRES ST
Practice Address - Street 2:
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-1097
Practice Address - Country:US
Practice Address - Phone:815-224-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL142.0200191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical