Provider Demographics
NPI:1669867917
Name:VAIL, MATTHEW (LCSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VAIL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2232 W GIDDINGS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2002
Mailing Address - Country:US
Mailing Address - Phone:503-539-1027
Mailing Address - Fax:
Practice Address - Street 1:2232 W GIDDINGS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2002
Practice Address - Country:US
Practice Address - Phone:503-539-1027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490174501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical