Provider Demographics
NPI:1881330355
Name:MARTINEZ, AMANDA RAQUEL (MSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAQUEL
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 RIDGEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60554-5049
Mailing Address - Country:US
Mailing Address - Phone:331-278-8484
Mailing Address - Fax:
Practice Address - Street 1:725 RIDGEVIEW LN
Practice Address - Street 2:
Practice Address - City:SUGAR GROVE
Practice Address - State:IL
Practice Address - Zip Code:60554-5049
Practice Address - Country:US
Practice Address - Phone:331-278-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)