Provider Demographics
NPI:1609365063
Name:MARTIN, RICHARD A (LCSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 HAPPY LANDING DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-9463
Mailing Address - Country:US
Mailing Address - Phone:618-973-1401
Mailing Address - Fax:
Practice Address - Street 1:2980 BAKER DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5901
Practice Address - Country:US
Practice Address - Phone:217-492-4955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0092701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.009270OtherLICENSED CLINICAL SOCIAL WORKER