Provider Demographics
NPI:1942404264
Name:MARTIN, MICHELE MARION (LMFT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARION
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 SHERIDAN RD
Mailing Address - Street 2:APT. 2 SOUTH
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3193
Mailing Address - Country:US
Mailing Address - Phone:847-733-0319
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:SUITE 601
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4508
Practice Address - Country:US
Practice Address - Phone:847-624-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166000697106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist