Provider Demographics
NPI:1104242940
Name:MANN, MARTHA (LCSW)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:MANN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1012
Mailing Address - Country:US
Mailing Address - Phone:312-655-7222
Mailing Address - Fax:312-879-0293
Practice Address - Street 1:651 W LAKE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-1012
Practice Address - Country:US
Practice Address - Phone:312-655-7222
Practice Address - Fax:312-879-0293
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490086911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical