=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134279664
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONSTANCE M. MARTIN PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 01/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7101 N CICERO AVE SUITE 203
-----------------------------------------------------
City | LINCOLNWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60712-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-458-9086
-----------------------------------------------------
Fax | 847-983-4783
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7101 N CICERO AVE SUITE 203
-----------------------------------------------------
City | LINCOLNWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60712-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-458-9086
-----------------------------------------------------
Fax | 847-983-4783
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071-005433
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------