Healthcare Provider Details

I. General information

NPI: 1912002627
Provider Name (Legal Business Name): MICHELLE ADRIAN MATTHEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 A ST
ELGIN OK
73538-2153
US

IV. Provider business mailing address

201 CRESTVIEW DR
ELGIN OK
73538-8906
US

V. Phone/Fax

Practice location:
  • Phone: 580-919-6511
  • Fax:
Mailing address:
  • Phone: 580-919-6511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7134
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: