Provider Demographics
NPI:1235663279
Name:CALVERT, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:CALVERT
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 1:16351 US HIGHWAY 75
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-5036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 E LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-2676
Practice Address - Country:US
Practice Address - Phone:580-927-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10987101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health