Provider Demographics
NPI:1598991879
Name:MATIAS, TERESA (PT)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:
Last Name:MATIAS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:EWING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:2674 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4917
Practice Address - Country:US
Practice Address - Phone:847-336-8089
Practice Address - Fax:847-336-8079
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2515-024225100000X
IL070-005449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL539320005OtherMEDICARE
ILP01119496OtherRAIL ROAD MEDICARE
WI859400055OtherMEDICARE
ILIL6697002OtherMEDICARE
ILIL6237007OtherMEDICARE
IL205086005OtherMEDICARE
ILIL6238007OtherMEDICARE