Provider Demographics
NPI:1336514488
Name:JOHNSON, MARTA L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARTA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2542 N KEDZIE BLVD
Mailing Address - Street 2:UNIT 209
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2679
Mailing Address - Country:US
Mailing Address - Phone:217-556-8629
Mailing Address - Fax:
Practice Address - Street 1:500 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1042
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3777
Practice Address - Country:US
Practice Address - Phone:312-508-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0163141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical