Healthcare Provider Details

I. General information

NPI: 1841775772
Provider Name (Legal Business Name): ELLI MARIE MATKIN LCSW, ROLFER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N HIGGINS AVE STE 220
MISSOULA MT
59802-4443
US

IV. Provider business mailing address

1329 SHERWOOD ST
MISSOULA MT
59802-2301
US

V. Phone/Fax

Practice location:
  • Phone: 509-540-2418
  • Fax:
Mailing address:
  • Phone: 509-540-2418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBBH-LCSW-LIC-55311
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: