Provider Demographics
NPI:1124599022
Name:WAXLER, MATTHEW JORDAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JORDAN
Last Name:WAXLER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 N DOVER ST APT 3S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-6258
Mailing Address - Country:US
Mailing Address - Phone:847-226-9245
Mailing Address - Fax:
Practice Address - Street 1:6600 N LINCOLN AVE STE 211
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-3641
Practice Address - Country:US
Practice Address - Phone:847-226-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2653103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical