Provider Demographics
NPI:1144516584
Name:OBERT, MATHIAS R (LCSW)
Entity type:Individual
Prefix:MR
First Name:MATHIAS
Middle Name:R
Last Name:OBERT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 AUDUBON LN
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-0643
Mailing Address - Country:US
Mailing Address - Phone:217-222-4633
Mailing Address - Fax:
Practice Address - Street 1:205 S 24TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4446
Practice Address - Country:US
Practice Address - Phone:217-222-0034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.014409101Y00000X, 103K00000X, 1041C0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251S00000XAgenciesCommunity/Behavioral Health