Healthcare Provider Details

I. General information

NPI: 1134253446
Provider Name (Legal Business Name): MAT-SU SERVICES FOR CHILDREN & ADULTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 SHENNUM DR
WASILLA AK
99654-7718
US

IV. Provider business mailing address

5000 SHENNUM DR
WASILLA AK
99654-7718
US

V. Phone/Fax

Practice location:
  • Phone: 907-352-1200
  • Fax: 907-352-1249
Mailing address:
  • Phone: 907-352-1200
  • Fax: 907-352-1249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number403503
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCMG450
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: SUSAN GARNER
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 907-352-1200