Provider Demographics
NPI:1790224764
Name:MATHEWS, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 N LEAVITT ST
Mailing Address - Street 2:2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-1531
Mailing Address - Country:US
Mailing Address - Phone:608-289-4699
Mailing Address - Fax:
Practice Address - Street 1:4721 N LEAVITT ST
Practice Address - Street 2:2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1531
Practice Address - Country:US
Practice Address - Phone:608-289-4699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist