Provider Demographics
NPI:1407381080
Name:MATHEWS, COLLEEN (PTA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W WOOD ST
Mailing Address - Street 2:
Mailing Address - City:PEOTONE
Mailing Address - State:IL
Mailing Address - Zip Code:60468-9010
Mailing Address - Country:US
Mailing Address - Phone:708-935-9865
Mailing Address - Fax:
Practice Address - Street 1:1201 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:BEECHER
Practice Address - State:IL
Practice Address - Zip Code:60401-4040
Practice Address - Country:US
Practice Address - Phone:708-946-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2023-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006598225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant