Provider Demographics
NPI:1720210719
Name:MARTIRENA, LISA M (LCPC, MT-BC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:MARTIRENA
Suffix:
Gender:F
Credentials:LCPC, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10540 S WESTERN AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2536
Mailing Address - Country:US
Mailing Address - Phone:773-319-8138
Mailing Address - Fax:
Practice Address - Street 1:10540 S WESTERN AVE
Practice Address - Street 2:STE. 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2536
Practice Address - Country:US
Practice Address - Phone:773-319-8138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008411101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health