Provider Demographics
NPI:1528131208
Name:MARTIN, KATHARINE (LCPC)
Entity type:Individual
Prefix:
First Name:KATHARINE
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 1:2930 MONTVALE DR STE E
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5376
Mailing Address - Country:US
Mailing Address - Phone:217-717-4399
Mailing Address - Fax:217-717-4399
Practice Address - Street 1:1224 CENTRE WEST DR STE 200E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-2194
Practice Address - Country:US
Practice Address - Phone:217-717-4399
Practice Address - Fax:217-717-4399
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-004787101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
669465OtherHEALTHLINK
ILMAGELLANOther732371000
IL8432104OtherBLUE SHIELD