Provider Demographics
NPI:1376307066
Name:WOHLGEMUTH, MATTHEW ERICH (LSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ERICH
Last Name:WOHLGEMUTH
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3243
Mailing Address - Country:US
Mailing Address - Phone:847-691-8792
Mailing Address - Fax:
Practice Address - Street 1:778 W FRONTAGE RD STE 104
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1209
Practice Address - Country:US
Practice Address - Phone:847-291-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1066081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty