Provider Demographics
NPI:1275088114
Name:MARTENSON, MATTHEW JOHN (MSED, NCC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:MARTENSON
Suffix:
Gender:M
Credentials:MSED, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 E 38TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1168
Mailing Address - Country:US
Mailing Address - Phone:563-424-2016
Mailing Address - Fax:563-424-2017
Practice Address - Street 1:2028 E 38TH ST STE 4
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1168
Practice Address - Country:US
Practice Address - Phone:563-424-2016
Practice Address - Fax:563-424-2017
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-21
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087950101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1275088114Medicaid