Healthcare Provider Details

I. General information

NPI: 1699606434
Provider Name (Legal Business Name): MICHELLE MATA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 LAKEVIEW PKWY STE 150
VERNON HILLS IL
60061-1839
US

IV. Provider business mailing address

1454 CARRIAGE LN
LAKE VILLA IL
60046-7003
US

V. Phone/Fax

Practice location:
  • Phone: 877-486-4140
  • Fax:
Mailing address:
  • Phone: 224-308-2415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: