Provider Demographics
NPI:1174829899
Name:LANGEDYKE, MATTHEW PATRICK (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PATRICK
Last Name:LANGEDYKE
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:19200 N KELSEY ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272
Practice Address - Country:US
Practice Address - Phone:425-316-5062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW6033223104100000X
WALW603322331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker