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General NPI Number Information
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NPI Number | 1386235596
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Entity Type | Individual
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Provider Name | GINA C MARTIN
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Gender | Female
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Dates
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Enumeration Date | 01/30/2021
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Last Update Date | 01/30/2021
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Provider Practice Location Address
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Address Line | 900 NORTH SHORE DR
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City | LAKE BLUFF
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State | IL
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Zip | 60044-2243
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Country | US
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Telephone | 847-271-8023
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Fax |
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Provider Business Mailing Address
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Address Line | 63 COLCHESTER DR
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City | IOWA CITY
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State | IA
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Zip | 52245-9333
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Country | US
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Telephone | 847-271-8023
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 178013726
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License Number State | IL
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