MEDICARE: JOAN ANNE MATLOCK MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	LMFT15099	AZ

General Provider Information

NPI Number	:	1336295518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOAN ANNE MATLOCK MFT

Provider Business Mailing Address
First Line	:	4652 N 31ST ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-5013
Country	:	US
Telephone Number	:	623-396-5690
Fax Number	:

Provider Business Practice Location Address
First Line	:	4652 N 31ST ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-5013
Country	:	US
Telephone Number	:	623-396-5690
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2007
Last Update Date	:	06/09/2022

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