Healthcare Provider Details

I. General information

NPI: 1376189522
Provider Name (Legal Business Name): SEASON MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9944 S ROBERTS RD
PALOS HILLS IL
60465-1690
US

IV. Provider business mailing address

5652 S RUTHERFORD AVE
CHICAGO IL
60638-3247
US

V. Phone/Fax

Practice location:
  • Phone: 708-586-9050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.014655
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number208.000704
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: