Provider Demographics
NPI:1104360080
Name:MATOS, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MATOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 DUNDEE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2462
Mailing Address - Country:US
Mailing Address - Phone:847-919-9096
Mailing Address - Fax:
Practice Address - Street 1:3100 DUNDEE RD STE 101
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2462
Practice Address - Country:US
Practice Address - Phone:847-919-9096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178-009299101YP2500X
IL180011597101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional