Provider Demographics
NPI:1457490088
Name:MATLOCK, DENNIS MARK (RS1503)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:MARK
Last Name:MATLOCK
Suffix:
Gender:M
Credentials:RS1503
Other - Prefix:
Other - First Name:DENNIS
Other - Middle Name:MARK
Other - Last Name:MATLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RS1503
Mailing Address - Street 1:PO BOX 2023
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92286-2023
Mailing Address - Country:US
Mailing Address - Phone:760-347-0754
Mailing Address - Fax:
Practice Address - Street 1:83912 AVENUE 45 STE 9
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3338
Practice Address - Country:US
Practice Address - Phone:760-347-0754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)