Provider Demographics
NPI:1114170826
Name:DAHLSTEN, MATTHEW JOSEPH (LPCC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:DAHLSTEN
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DEMOSS ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:575-542-2388
Practice Address - Street 1:1720 E. 32ND ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061
Practice Address - Country:US
Practice Address - Phone:575-388-4412
Practice Address - Fax:575-313-8236
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0143431101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid
NM18677037Medicaid