Provider Demographics
NPI:1003100181
Name:BARRUS, MATTHEW TY (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TY
Last Name:BARRUS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 RISEN SON RD
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-8473
Mailing Address - Country:US
Mailing Address - Phone:307-254-0575
Mailing Address - Fax:
Practice Address - Street 1:1106 JULIE LN
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-1632
Practice Address - Country:US
Practice Address - Phone:307-271-7460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-5821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical