Provider Demographics
NPI:1508151796
Name:ACKENHAUSEN, MATTHEW ALLEN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALLEN
Last Name:ACKENHAUSEN
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 1:3031 E 84TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-1414
Mailing Address - Country:US
Mailing Address - Phone:918-282-3654
Mailing Address - Fax:
Practice Address - Street 1:3031 E 84TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-1414
Practice Address - Country:US
Practice Address - Phone:918-282-3654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical