Provider Demographics
NPI:1023352382
Name:MARTIN, KELLY JANE (LCPC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JANE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 W GRANVILLE AVE
Mailing Address - Street 2:UNIT 918
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2092
Mailing Address - Country:US
Mailing Address - Phone:773-512-0259
Mailing Address - Fax:
Practice Address - Street 1:2551 N CLARK ST
Practice Address - Street 2:SUITE 800
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1798
Practice Address - Country:US
Practice Address - Phone:773-512-0259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008420101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional