Provider Demographics
NPI:1508189176
Name:MARTIN, TRACY E (MSED, LCPC)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:E
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MSED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-2872
Mailing Address - Country:US
Mailing Address - Phone:815-289-2211
Mailing Address - Fax:
Practice Address - Street 1:7700 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-2872
Practice Address - Country:US
Practice Address - Phone:815-289-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006311101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional