Provider Demographics
NPI:1538216106
Name:MOLENAAR, MATTHEW (LCSW)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:MOLENAAR
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 1:3546 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-3146
Mailing Address - Country:US
Mailing Address - Phone:773-771-9189
Mailing Address - Fax:708-895-2385
Practice Address - Street 1:3546 RIDGE RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-3146
Practice Address - Country:US
Practice Address - Phone:773-771-9189
Practice Address - Fax:708-895-2385
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7370547Medicare UPIN
IL212757Medicare ID - Type Unspecified
IL1634583Medicare UPIN