Healthcare Provider Details

I. General information

NPI: 1144161019
Provider Name (Legal Business Name): MATSEN GWYN HARTSOE PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 W 4TH ST
WINSTON SALEM NC
27101-2437
US

IV. Provider business mailing address

4585 HENNINGS DR
COLORADO SPRINGS CO
80911-3225
US

V. Phone/Fax

Practice location:
  • Phone: 336-283-6081
  • Fax:
Mailing address:
  • Phone: 336-409-3916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: