Healthcare Provider Details

I. General information

NPI: 1043223613
Provider Name (Legal Business Name): MATTHEW ERIC DENIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3412 S ILLINOIS AVE
CARBONDALE IL
62903-8362
US

IV. Provider business mailing address

3412 S ILLINOIS AVE
CARBONDALE IL
62903-8362
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-4488
  • Fax: 618-457-8844
Mailing address:
  • Phone: 618-457-4488
  • Fax: 618-457-8844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005515
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: