Provider Demographics
NPI:1235856477
Name:FENN, MATTHEW BRYAN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRYAN
Last Name:FENN
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 1:415 S 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-3630
Mailing Address - Country:US
Mailing Address - Phone:402-516-4775
Mailing Address - Fax:
Practice Address - Street 1:415 S 25TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-3630
Practice Address - Country:US
Practice Address - Phone:402-717-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13212101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health