Provider Demographics
NPI:1619274438
Name:CONANT, MATTHEW B (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:CONANT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:21806 103RD AVENUE CT E
Practice Address - Street 2:STE 103
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-8115
Practice Address - Country:US
Practice Address - Phone:253-847-3700
Practice Address - Fax:253-847-9622
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012651225100000X
WAPT 60520702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202845166Medicare PIN
IL216859156Medicare PIN