Healthcare Provider Details

I. General information

NPI: 1487935698
Provider Name (Legal Business Name): JANEE MARTIN LCAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3465 192ND ST
LANSING IL
60438-3813
US

IV. Provider business mailing address

3465 192ND ST
LANSING IL
60438-3813
US

V. Phone/Fax

Practice location:
  • Phone: 708-889-6256
  • Fax:
Mailing address:
  • Phone: 708-889-6256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001054A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: