Provider Demographics
NPI:1154955037
Name:MARTIN SRAJEK, PHD., LCSW, LTD
Entity type:Organization
Organization Name:MARTIN SRAJEK, PHD., LCSW, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SRAJEK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW
Authorized Official - Phone:217-637-2138
Mailing Address - Street 1:206 N RANDOLPH ST STE 534-36
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3949
Mailing Address - Country:US
Mailing Address - Phone:217-637-2138
Mailing Address - Fax:217-355-4911
Practice Address - Street 1:206 N RANDOLPH ST STE 534-36
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3949
Practice Address - Country:US
Practice Address - Phone:217-637-2138
Practice Address - Fax:217-355-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS622-5686-1037OtherDRIVERS LICENSE
IL1730392481OtherINDIVIDUAL NPI