=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386776342
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES MATTHEWS MA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9343 S RIDGELAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-3637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-221-9024
-----------------------------------------------------
Fax | 773-221-8006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9343 S RIDGELAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-3637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-221-9024
-----------------------------------------------------
Fax | 773-221-8006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------