Provider Demographics
NPI:1457661571
Name:BECKER, MATTHEW THOMAS (BA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:THOMAS
Last Name:BECKER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 PALMYRA ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1126 HEALTHCARE DR
Practice Address - Street 2:
Practice Address - City:MOUNT CARROLL
Practice Address - State:IL
Practice Address - Zip Code:61053-1469
Practice Address - Country:US
Practice Address - Phone:184-524-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness