MEDICARE: KATHARINE MARTIN LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180-004787	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	669465	OTHER		HEALTHLINK
2	MAGELLAN	OTHER	IL	732371000
3	8432104	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1528131208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHARINE MARTIN LCPC

Provider Business Mailing Address
First Line	:	2930 MONTVALE DR STE E
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-5376
Country	:	US
Telephone Number	:	217-717-4399
Fax Number	:	217-717-4399

Provider Business Practice Location Address
First Line	:	1224 CENTRE WEST DR STE 200E
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-2194
Country	:	US
Telephone Number	:	217-717-4399
Fax Number	:	217-717-4399

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	12/04/2023

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Directions to “ KATHARINE MARTIN LCPC” Practice Location

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