Provider Demographics
NPI:1396260410
Name:MARTIN, MAUREEN M (LCPC)
Entity type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:M
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 1:520 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3030
Mailing Address - Country:US
Mailing Address - Phone:847-275-3980
Mailing Address - Fax:
Practice Address - Street 1:1585 ELLINWOOD AVE STE 106
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-4535
Practice Address - Country:US
Practice Address - Phone:847-877-3970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.007808101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional