Healthcare Provider Details

I. General information

NPI: 1871155614
Provider Name (Legal Business Name): TIA NICOLE MARTINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 22ND ST STE A
LOMBARD IL
60148-6104
US

IV. Provider business mailing address

534 N LECLAIRE AVE
CHICAGO IL
60644-1885
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-1500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: