Healthcare Provider Details

I. General information

NPI: 1649645110
Provider Name (Legal Business Name): CODY ELIZABETH MARTIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 06/21/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 W ROHMANN AVE
WEST PEORIA IL
61604-4842
US

IV. Provider business mailing address

4704 N EDGEBROOK DR
PEORIA IL
61614-6014
US

V. Phone/Fax

Practice location:
  • Phone: 309-671-0300
  • Fax:
Mailing address:
  • Phone: 309-892-0243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.031934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: