Healthcare Provider Details

I. General information

NPI: 1184285322
Provider Name (Legal Business Name): MATTHEW DENNISTON LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WAYNE AVE
DAYTON OH
45410-1122
US

IV. Provider business mailing address

600 WAYNE AVE
DAYTON OH
45410-1122
US

V. Phone/Fax

Practice location:
  • Phone: 937-496-2000
  • Fax:
Mailing address:
  • Phone: 937-496-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.2005215
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: