Provider Demographics
NPI:1376268938
Name:KEZON, MARTIN J (LSW)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:J
Last Name:KEZON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10939 S MILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-3316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 W DIVERSEY PKWY STE 275
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1879
Practice Address - Country:US
Practice Address - Phone:773-281-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.109215104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker