Provider Demographics
NPI:1386179430
Name:MARONICK, MATTHEW (AM, MPP, LSW)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:MARONICK
Suffix:
Gender:M
Credentials:AM, MPP, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:TILTON
Mailing Address - State:IL
Mailing Address - Zip Code:61833-8109
Mailing Address - Country:US
Mailing Address - Phone:443-682-0360
Mailing Address - Fax:
Practice Address - Street 1:1630 GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:TILTON
Practice Address - State:IL
Practice Address - Zip Code:61833-8109
Practice Address - Country:US
Practice Address - Phone:443-682-0360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst