Provider Demographics
NPI:1780822528
Name:MATTERA, LAURIE J (PHD)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:J
Last Name:MATTERA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:EDENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:909 E PALATINE RD
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-5551
Mailing Address - Country:US
Mailing Address - Phone:847-776-1400
Mailing Address - Fax:847-776-1864
Practice Address - Street 1:909 E PALATINE RD
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-5551
Practice Address - Country:US
Practice Address - Phone:847-776-1400
Practice Address - Fax:847-776-1864
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-007460103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK30705Medicare PIN