Provider Demographics
NPI:1316345416
Name:MARTIN, ANGELA (LPC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 57TH ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-4146
Mailing Address - Country:US
Mailing Address - Phone:262-656-0044
Mailing Address - Fax:262-764-3636
Practice Address - Street 1:4536 22ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5917
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:262-764-3636
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5462-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional