Provider Demographics
NPI:1679200562
Name:THOMAS, MATTHEW B (LSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:THOMAS
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 N COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-3463
Mailing Address - Country:US
Mailing Address - Phone:630-336-9758
Mailing Address - Fax:
Practice Address - Street 1:474 BRIARGATE DR
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-2225
Practice Address - Country:US
Practice Address - Phone:630-587-3777
Practice Address - Fax:630-587-3791
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.108758104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty