Provider Demographics
NPI:1679958011
Name:CERMAK, MATTHEW EDWARD (MSW LSW CADC MISA-1)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:EDWARD
Last Name:CERMAK
Suffix:
Gender:M
Credentials:MSW LSW CADC MISA-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 WILLIAMSBURG AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134
Mailing Address - Country:US
Mailing Address - Phone:815-520-1181
Mailing Address - Fax:
Practice Address - Street 1:2631 WILLIAMSBURG AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-1107
Practice Address - Country:US
Practice Address - Phone:815-520-1181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL32399101YA0400X
IL150015736104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3884947OtherFEIN