Healthcare Provider Details

I. General information

NPI: 1346058708
Provider Name (Legal Business Name): MR. MATTHEW TYLER ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 ELLSWORTH ST
MARTINSVILLE VA
24112-2812
US

IV. Provider business mailing address

250 FLINTWOOD DR
BASSETT VA
24055-3435
US

V. Phone/Fax

Practice location:
  • Phone: 276-632-0035
  • Fax:
Mailing address:
  • Phone: 276-229-5694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: