Healthcare Provider Details

I. General information

NPI: 1518877109
Provider Name (Legal Business Name): AMANDA NICOLE MARTIN LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15601 US HIGHWAY 150
PARIS IL
61944-6071
US

IV. Provider business mailing address

15601 US HIGHWAY 150
PARIS IL
61944-6071
US

V. Phone/Fax

Practice location:
  • Phone: 217-465-5391
  • Fax:
Mailing address:
  • Phone: 217-465-5391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number2714573
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: