Provider Demographics
NPI:1215629548
Name:TETEAK, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:TETEAK
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 1:2824 SEILER DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-4371
Mailing Address - Country:US
Mailing Address - Phone:630-429-5332
Mailing Address - Fax:
Practice Address - Street 1:2104 GREENBRIAR DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-8355
Practice Address - Country:US
Practice Address - Phone:847-442-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-16-15039106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician