Provider Demographics
NPI:1235694126
Name:MATTISON, TAHLOR E (CTD)
Entity Type:Individual
Prefix:
First Name:TAHLOR
Middle Name:E
Last Name:MATTISON
Suffix:
Gender:F
Credentials:CTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 BRENNER CT
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60411-4623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15774 S LA GRANGE RD STE 272
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4766
Practice Address - Country:US
Practice Address - Phone:312-478-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL193200000X174N00000X, 374J00000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula