Provider Demographics
NPI:1417398645
Name:MARTINEZ, NICOLE MARA (PSYD, LCPC)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:PSYD, LCPC
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:MARA
Other - Last Name:MAIDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 24449 SUITE 201
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-0001
Mailing Address - Country:US
Mailing Address - Phone:917-634-5311
Mailing Address - Fax:
Practice Address - Street 1:250 PARKWAY DR STE 150
Practice Address - Street 2:
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-4340
Practice Address - Country:US
Practice Address - Phone:917-634-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008146101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.008146OtherLICENSE