Provider Demographics
NPI:1144647405
Name:MATA, GEMMA
Entity type:Individual
Prefix:
First Name:GEMMA
Middle Name:
Last Name:MATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6833 N KEDZIE AVE
Mailing Address - Street 2:APT 810
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-2897
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6833 N KEDZIE AVE
Practice Address - Street 2:APT 810
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-2897
Practice Address - Country:US
Practice Address - Phone:773-645-5167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017756225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist