Provider Demographics
NPI:1194280024
Name:GOVEDNIK, MATTHEW J
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:GOVEDNIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 W BERGERA RD
Mailing Address - Street 2:
Mailing Address - City:BRAIDWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60408-1657
Mailing Address - Country:US
Mailing Address - Phone:815-302-0101
Mailing Address - Fax:
Practice Address - Street 1:300 E MAZON AVE
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420-1104
Practice Address - Country:US
Practice Address - Phone:815-584-1240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant