Healthcare Provider Details

I. General information

NPI: 1518670371
Provider Name (Legal Business Name): MATTHEW IWATA LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2022
Last Update Date: 12/26/2022
Certification Date: 12/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 GRAND AVE UNIT 211
SAINT PAUL MN
55105-3820
US

IV. Provider business mailing address

2136 FORD PKWY # 5481
SAINT PAUL MN
55116-2850
US

V. Phone/Fax

Practice location:
  • Phone: 612-208-2865
  • Fax:
Mailing address:
  • Phone: 612-208-2865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24616
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: