Provider Demographics
NPI:1417643875
Name:MATTHEWS, ROOSEVELT
Entity Type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:MATTHEWS
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 1:13325 AVANTS AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-6969
Mailing Address - Country:US
Mailing Address - Phone:225-266-4776
Mailing Address - Fax:
Practice Address - Street 1:13325 AVANTS AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-6969
Practice Address - Country:US
Practice Address - Phone:225-266-4776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator