MEDICARE: DR. LAURA L MATHIS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01636351	OTHER	IL	BLUECROSS BLUESHIELD PPO

General Provider Information

NPI Number	:	1053462465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA L MATHIS PSYD

Provider Business Mailing Address
First Line	:	200 N DEARBORN ST
Second Line	:	#2007
City	:	CHICAGO
State	:	IL
Zip	:	60601-1616
Country	:	US
Telephone Number	:	312-218-7409
Fax Number	:

Provider Business Practice Location Address
First Line	:	77 W WASHINGTON ST
Second Line	:	#1911
City	:	CHICAGO
State	:	IL
Zip	:	60602-2801
Country	:	US
Telephone Number	:	312-218-7409
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2007
Last Update Date	:	07/08/2007

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