Provider Demographics
NPI:1659581247
Name:BLACKMAN, MARTIN HOWARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:HOWARD
Last Name:BLACKMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3440
Mailing Address - Country:US
Mailing Address - Phone:847-614-8936
Mailing Address - Fax:847-256-0447
Practice Address - Street 1:207 3RD ST
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-3440
Practice Address - Country:US
Practice Address - Phone:847-614-8936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical