Provider Demographics
NPI:1336379320
Name:MATTESON, COLLEEN ELIZABETH (SLP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ELIZABETH
Last Name:MATTESON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:ELIZABETH
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3411 AVONDALE LN
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-8602
Mailing Address - Country:US
Mailing Address - Phone:708-308-6859
Mailing Address - Fax:
Practice Address - Street 1:3411 AVONDALE LN
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-8602
Practice Address - Country:US
Practice Address - Phone:708-308-6859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.009893235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist