=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750002275
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW MARKOWICZ LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2022
-----------------------------------------------------
Last Update Date | 09/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10611 PATTERSON AVE
-----------------------------------------------------
City | HENRICO
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23238-4733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-592-0811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7209 ELKHARDT RD
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23225-7413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-380-0986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904013946
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------