Provider Demographics
NPI:1689274763
Name:FETROW, MATTHEW L
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:FETROW
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 GREEN BAY RD BLDG 7
Mailing Address - Street 2:
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-3048
Mailing Address - Country:US
Mailing Address - Phone:224-610-4938
Mailing Address - Fax:
Practice Address - Street 1:3408 WESTMINISTER ST
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-4844
Practice Address - Country:US
Practice Address - Phone:832-736-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IL149.0235481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker