Healthcare Provider Details

I. General information

NPI: 1932537990
Provider Name (Legal Business Name): MATTHEW LEE CUDDEBACK L.C.S.W
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-425-6400
  • Fax: 847-425-6408
Mailing address:
  • Phone: 847-982-3175
  • Fax: 847-982-3394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149016063
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: