1154955037 NPI number — MARTIN SRAJEK, PHD., LCSW, LTD

Table of content: (NPI 1154955037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154955037 NPI number — MARTIN SRAJEK, PHD., LCSW, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTIN SRAJEK, PHD., LCSW, LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154955037
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 N RANDOLPH ST STE 534-36
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61820-3949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-637-2138
Provider Business Mailing Address Fax Number:
217-355-4911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 N RANDOLPH ST STE 534-36
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820-3949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-637-2138
Provider Business Practice Location Address Fax Number:
217-355-4911
Provider Enumeration Date:
02/28/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SRAJEK
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
217-637-2138

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: S622-5686-1037 . This is a "DRIVERS LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1730392481 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".