Healthcare Provider Details

I. General information

NPI: 1073790416
Provider Name (Legal Business Name): MICHELLE R MATZKE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 N BENT ST STE K
POWELL WY
82435-2335
US

IV. Provider business mailing address

PO BOX 1200
POWELL WY
82435-1200
US

V. Phone/Fax

Practice location:
  • Phone: 406-219-1477
  • Fax: 888-929-8661
Mailing address:
  • Phone: 406-219-1477
  • Fax: 888-929-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number750
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6919
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1953
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: