Healthcare Provider Details

I. General information

NPI: 1639136088
Provider Name (Legal Business Name): MATTHEW D CHRISTIANSEN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 09/08/2024
Certification Date: 09/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E HAVENS AVE STE 102
MITCHELL SD
57301-4462
US

IV. Provider business mailing address

PO BOX 1303
MITCHELL SD
57301-7303
US

V. Phone/Fax

Practice location:
  • Phone: 605-299-2829
  • Fax:
Mailing address:
  • Phone: 605-299-2829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number488
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierSD449
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerDAKOTACARE
# 2
Identifier33171
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerSIOUX VALLEY HEALTH
# 3
Identifier91400318
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 4
Identifier9189
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerAVERA HEALTH
# 5
Identifier4995782
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerWELLMARK BC BS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: