Provider Demographics
NPI:1780442574
Name:FORD, MATTHEW (PEL)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FORD
Suffix:
Gender:M
Credentials:PEL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 LUCILLE LN
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-5352
Mailing Address - Country:US
Mailing Address - Phone:630-337-1486
Mailing Address - Fax:
Practice Address - Street 1:81 S MCLEAN BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-1859
Practice Address - Country:US
Practice Address - Phone:630-596-3688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2385570101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional