Provider Demographics
NPI:1417398645
Name:MARTINEZ, NICOLE MARA (PSYD, LCPC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PSYD, LCPC
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:MARA
Other - Last Name:MAIDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:465 CENTRAL AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3045
Mailing Address - Country:US
Mailing Address - Phone:847-686-0090
Mailing Address - Fax:847-686-0090
Practice Address - Street 1:465 CENTRAL AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3045
Practice Address - Country:US
Practice Address - Phone:847-686-0090
Practice Address - Fax:847-686-0090
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008146101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.008146OtherLICENSE