Provider Demographics
NPI:1538372974
Name:MARTINEZ, SELMA (BCBA)
Entity type:Individual
Prefix:
First Name:SELMA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 DAYBREAK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-6409
Mailing Address - Country:US
Mailing Address - Phone:855-690-2192
Mailing Address - Fax:888-972-2192
Practice Address - Street 1:10769 BROADWAY STE 208
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7316
Practice Address - Country:US
Practice Address - Phone:855-690-2192
Practice Address - Fax:888-972-2192
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1021012101YP2500X
222Q00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist