Provider Demographics
NPI:1851682207
Name:GATES, MARTHA (LPC)
Entity Type:Individual
Prefix:MISS
First Name:MARTHA
Middle Name:
Last Name:GATES
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 1:500 PARK AVENUE
Mailing Address - Street 2:UNIT #631
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-5034
Mailing Address - Country:US
Mailing Address - Phone:708-837-4673
Mailing Address - Fax:
Practice Address - Street 1:1525 EAST 53RD STREET
Practice Address - Street 2:SUITE #503
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615
Practice Address - Country:US
Practice Address - Phone:708-837-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178-003019101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
9325686OtherAETNA