Healthcare Provider Details

I. General information

NPI: 1407381080
Provider Name (Legal Business Name): COLLEEN MATHEWS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 04/02/2023
Certification Date: 04/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 DIXIE HWY
BEECHER IL
60401-4040
US

IV. Provider business mailing address

417 W WOOD ST
PEOTONE IL
60468-9010
US

V. Phone/Fax

Practice location:
  • Phone: 708-946-2600
  • Fax:
Mailing address:
  • Phone: 708-935-9865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160006598
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: