Provider Demographics
NPI:1467563205
Name:MARTIN, MARK RANDALL (LCPC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RANDALL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 BROOKSHIRE GRN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6211
Mailing Address - Country:US
Mailing Address - Phone:309-663-8243
Mailing Address - Fax:
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:EMP II LL 1000
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3534
Practice Address - Country:US
Practice Address - Phone:309-663-1623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional