Provider Demographics
NPI:1629541586
Name:MARTI, AMANDA LYN (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYN
Last Name:MARTI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 NORTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1077
Mailing Address - Country:US
Mailing Address - Phone:618-623-9148
Mailing Address - Fax:
Practice Address - Street 1:644 N 2ND ST STE 4
Practice Address - Street 2:
Practice Address - City:BREESE
Practice Address - State:IL
Practice Address - Zip Code:62230-1614
Practice Address - Country:US
Practice Address - Phone:314-881-8135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL178.015105101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor