Healthcare Provider Details

I. General information

NPI: 1477475952
Provider Name (Legal Business Name): ODALYS MARY COLON MARTINEZ PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

974 W BERGERA RD
BRAIDWOOD IL
60408-1658
US

IV. Provider business mailing address

974 W BERGERA RD
BRAIDWOOD IL
60408-1658
US

V. Phone/Fax

Practice location:
  • Phone: 815-258-0418
  • Fax:
Mailing address:
  • Phone: 815-608-1089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071.022412
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: