Provider Demographics
NPI:1518232388
Name:KNOWLTON, MATTHEW ROBERT (DPT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:KNOWLTON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 W WOLFRAM ST APT 515
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-8046
Mailing Address - Country:US
Mailing Address - Phone:618-567-3898
Mailing Address - Fax:
Practice Address - Street 1:345 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2654
Practice Address - Country:US
Practice Address - Phone:312-238-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist