Provider Demographics
NPI:1104867860
Name:NANCE, MATTHEW LEMUEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:LEMUEL
Last Name:NANCE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7515 MAIN ST STE 605
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4515
Mailing Address - Country:US
Mailing Address - Phone:713-796-9946
Mailing Address - Fax:713-796-9873
Practice Address - Street 1:7515 MAIN ST STE 605
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4515
Practice Address - Country:US
Practice Address - Phone:713-796-9946
Practice Address - Fax:713-796-9873
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-4693103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F3542Medicare PIN
TXR58372Medicare UPIN