Provider Demographics
NPI:1447792593
Name:MATZEN, TESSA (PCSW)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:MATZEN
Suffix:
Gender:F
Credentials:PCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4989 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-9548
Mailing Address - Country:US
Mailing Address - Phone:307-745-8997
Mailing Address - Fax:
Practice Address - Street 1:1607 CAPITOL AVE FL THE2
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4525
Practice Address - Country:US
Practice Address - Phone:307-630-4729
Practice Address - Fax:307-632-3298
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPCSW-685101Y00000X, 104100000X
LCSW-11301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYLCSW-1130OtherLICENSED CLINICAL SOCIAL WORKER
WYPCSW-685OtherSTATE LICENSE