Healthcare Provider Details

I. General information

NPI: 1356996128
Provider Name (Legal Business Name): MATTHEW MALONE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N RAYNOR AVE
JOLIET IL
60435-6065
US

IV. Provider business mailing address

17643 DOVER CT
TINLEY PARK IL
60487-8442
US

V. Phone/Fax

Practice location:
  • Phone: 815-740-3196
  • Fax:
Mailing address:
  • Phone: 773-531-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1862236
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: