Provider Demographics
NPI:1184215501
Name:MATTIS ROAD COUNSELING, LLC
Entity Type:Organization
Organization Name:MATTIS ROAD COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:D
Authorized Official - Last Name:KOPCHA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-334-2335
Mailing Address - Street 1:5151 MATTIS RD STE C
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2796
Mailing Address - Country:US
Mailing Address - Phone:314-334-2335
Mailing Address - Fax:314-334-2596
Practice Address - Street 1:5151 MATTIS RD STE C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2796
Practice Address - Country:US
Practice Address - Phone:314-952-2947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty