Provider Demographics
NPI:1205207040
Name:WOLFF, MATTHEW LAWSON
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LAWSON
Last Name:WOLFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 LINDULAKE DR
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-9325
Mailing Address - Country:US
Mailing Address - Phone:501-628-1837
Mailing Address - Fax:
Practice Address - Street 1:5307 JFK BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-6703
Practice Address - Country:US
Practice Address - Phone:501-392-6201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR15-0172355S0801X
AR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant