Provider Demographics
NPI:1942554472
Name:MARTIN, NICOLE (MS, LCPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 W GREGORY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1161
Mailing Address - Country:US
Mailing Address - Phone:872-216-9687
Mailing Address - Fax:
Practice Address - Street 1:1645 W GREGORY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1161
Practice Address - Country:US
Practice Address - Phone:872-216-9687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005462101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional