Healthcare Provider Details

I. General information

NPI: 1811647464
Provider Name (Legal Business Name): MATTHEW RONALD ATTEBURY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2022
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N MAIN ST
PRINCETON IN
47670-1540
US

IV. Provider business mailing address

108 N MAIN ST
PRINCETON IN
47670-1540
US

V. Phone/Fax

Practice location:
  • Phone: 812-753-1039
  • Fax:
Mailing address:
  • Phone: 812-753-1039
  • Fax: 812-753-1122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34009524A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: