Healthcare Provider Details

I. General information

NPI: 1750656567
Provider Name (Legal Business Name): MATTHEW WILLIAM HEFFERON PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3139 N LINCOLN AVE STE 222B
CHICAGO IL
60657-3141
US

IV. Provider business mailing address

856 W BUCKINGHAM PL 1W
CHICAGO IL
60657-2383
US

V. Phone/Fax

Practice location:
  • Phone: 312-669-4874
  • Fax:
Mailing address:
  • Phone: 312-669-4874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008309
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: