Provider Demographics
NPI:1457415325
Name:MARTINEZ, RONALD (LCPC)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 OAKLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244
Mailing Address - Country:US
Mailing Address - Phone:309-792-1074
Mailing Address - Fax:
Practice Address - Street 1:550 OAKLAWN AVE
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-4030
Practice Address - Country:US
Practice Address - Phone:309-792-1074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08132008OtherBLUE CROSS BLUE SHIELD IL