Healthcare Provider Details

I. General information

NPI: 1194888792
Provider Name (Legal Business Name): MATT PAVLIK MA, LPCC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 REGENCY RIDGE DR
DAYTON OH
45459-4221
US

IV. Provider business mailing address

267 REGENCY RIDGE DR
DAYTON OH
45459-4221
US

V. Phone/Fax

Practice location:
  • Phone: 937-396-7077
  • Fax:
Mailing address:
  • Phone: 937-776-7290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE6835
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberE6835
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE6835
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberE6835
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE6835
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: