Provider Demographics
NPI:1770212540
Name:HARRIS, MATTHEW B
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 W BRYN MAWR AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4273
Mailing Address - Country:US
Mailing Address - Phone:170-884-6896
Mailing Address - Fax:
Practice Address - Street 1:2451 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-3309
Practice Address - Country:US
Practice Address - Phone:773-338-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007033225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant