Provider Demographics
NPI:1982094744
Name:ILLES, JOHN MATTHEW (BA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MATTHEW
Last Name:ILLES
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4735 ROWAN RD
Mailing Address - Street 2:APT 213
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653
Mailing Address - Country:US
Mailing Address - Phone:727-645-7132
Mailing Address - Fax:
Practice Address - Street 1:5707 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4350
Practice Address - Country:US
Practice Address - Phone:813-239-8448
Practice Address - Fax:813-239-8513
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician