Provider Demographics
NPI:1174032007
Name:MARTIN, MELISSA (LCPC)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:1057 PONCA DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-1145
Mailing Address - Country:US
Mailing Address - Phone:773-329-0636
Mailing Address - Fax:
Practice Address - Street 1:2428 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2012
Practice Address - Country:US
Practice Address - Phone:773-329-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012613101YP2500X
IL180.012812101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL094307603OtherGOLDEN RULE- A UNITED HEALTHCARE COMPANY