Provider Demographics
NPI:1124430921
Name:MATUSZAK, MARY (CMMP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MATUSZAK
Suffix:
Gender:F
Credentials:CMMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6039 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2644
Mailing Address - Country:US
Mailing Address - Phone:708-362-0447
Mailing Address - Fax:773-424-0032
Practice Address - Street 1:6039 W 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2644
Practice Address - Country:US
Practice Address - Phone:773-424-0032
Practice Address - Fax:773-424-0032
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.016717174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist