Provider Demographics
NPI:1699467456
Name:MARTINEZ, MIRELLA (LSW)
Entity type:Individual
Prefix:
First Name:MIRELLA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 PHOENIX LN
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60431-8415
Mailing Address - Country:US
Mailing Address - Phone:219-256-0390
Mailing Address - Fax:
Practice Address - Street 1:16151 WEBER RD STE LL10
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-0863
Practice Address - Country:US
Practice Address - Phone:815-782-8263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.109636104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker