Provider Demographics
NPI:1083032619
Name:MATLOCK, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3149 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-6122
Mailing Address - Country:US
Mailing Address - Phone:307-203-9125
Mailing Address - Fax:
Practice Address - Street 1:3149 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-6122
Practice Address - Country:US
Practice Address - Phone:307-203-9125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services