Provider Demographics
NPI:1326654872
Name:MATLOCK, TAKASHI M
Entity Type:Individual
Prefix:
First Name:TAKASHI
Middle Name:M
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS NATIONAL PARK
Mailing Address - State:AR
Mailing Address - Zip Code:71901-3105
Mailing Address - Country:US
Mailing Address - Phone:501-551-1079
Mailing Address - Fax:
Practice Address - Street 1:339 JOY DR
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS NATIONAL PARK
Practice Address - State:AR
Practice Address - Zip Code:71913-8913
Practice Address - Country:US
Practice Address - Phone:501-551-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician