Provider Demographics
NPI:1487766762
Name:MARTIN, THOMAS E (PSYD, LCPC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PSYD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 GREEN BAY RD
Mailing Address - Street 2:BUILDING 9 116B
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-3048
Mailing Address - Country:US
Mailing Address - Phone:847-688-1900
Mailing Address - Fax:224-610-3869
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:BUILDING 9 116B
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:847-688-1900
Practice Address - Fax:224-610-3869
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL653160Medicare ID - Type Unspecified