Provider Demographics
NPI:1043548480
Name:SMITH-MATTHEWS, COURTNEY CLASSEN
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:CLASSEN
Last Name:SMITH-MATTHEWS
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 1:5359 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1450
Mailing Address - Country:US
Mailing Address - Phone:773-836-2785
Mailing Address - Fax:
Practice Address - Street 1:5359 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1450
Practice Address - Country:US
Practice Address - Phone:773-836-2785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004296133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered