Healthcare Provider Details

I. General information

NPI: 1154648160
Provider Name (Legal Business Name): KELLINE EVANS MATHEWS PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E ARMY TRAIL RD STE 306
BLOOMINGDALE IL
60108-2138
US

IV. Provider business mailing address

201 E ARMY TRAIL RD STE 306
BLOOMINGDALE IL
60108-2138
US

V. Phone/Fax

Practice location:
  • Phone: 630-539-2620
  • Fax:
Mailing address:
  • Phone: 630-539-2620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071.005973
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071.005973
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number071.005973
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number071.005973
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: