MEDICARE: MS. DOLORES JANE MATTHEWS MA

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	103T00000X	Psychologist	2240	MN
2	103TC1900X	Counseling Psychologist	2240	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10946MA	OTHER		BCBS
2	1581490	OTHER		MEDICA

General Provider Information

NPI Number	:	1487832564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DOLORES JANE MATTHEWS MA

Provider Business Mailing Address
First Line	:	23 4TH STREET SE
Second Line	:	#202
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-1090
Country	:	US
Telephone Number	:	612-379-8050
Fax Number	:	612-379-8069

Provider Business Practice Location Address
First Line	:	23 4TH STREET SE
Second Line	:	#202
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-1090
Country	:	US
Telephone Number	:	612-379-8050
Fax Number	:	612-379-8069

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

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	01/31/2008

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