Healthcare Provider Details

I. General information

NPI: 1376455444
Provider Name (Legal Business Name): NOAH JACOB MATTISON LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BIANCA MATTISON LSW

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 W ADAMS ST STE 1533
CHICAGO IL
60606-5138
US

IV. Provider business mailing address

700 MASSACHUSETTS AVE FL 3
CAMBRIDGE MA
02139-3345
US

V. Phone/Fax

Practice location:
  • Phone: 888-500-2067
  • Fax: 617-649-8520
Mailing address:
  • Phone: 888-500-2067
  • Fax: 617-649-8520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.130765
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: