Basic Information
Provider Information
NPI: 1003294786
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CHOUINARD
FirstName: MATTHEW
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1634 VALLEY RD
Address2:  
City: CHAMPAIGN
State: IL
PostalCode: 618207110
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 801 N WALNUT ST
Address2:  
City: CHAMPAIGN
State: IL
PostalCode: 618203055
CountryCode: US
TelephoneNumber: 2713732430
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/13/2015
LastUpdateDate: 05/13/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
104100000X  Y Behavioral Health & Social Service ProvidersSocial Worker 

No ID Information.


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