Provider Demographics
NPI:1033740055
Name:BOLTZ, MATTHEW GREGORY
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GREGORY
Last Name:BOLTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 N MICHIGAN AVE STE 325
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7591
Mailing Address - Country:US
Mailing Address - Phone:872-206-9718
Mailing Address - Fax:
Practice Address - Street 1:155 N MICHIGAN AVE STE 325
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7591
Practice Address - Country:US
Practice Address - Phone:872-206-9718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0219471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical