Provider Demographics
NPI:1518670371
Name:IWATA, MATTHEW (LICSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:IWATA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2136 FORD PKWY # 5481
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2850
Mailing Address - Country:US
Mailing Address - Phone:612-208-2865
Mailing Address - Fax:
Practice Address - Street 1:1060 GRAND AVE UNIT 211
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3820
Practice Address - Country:US
Practice Address - Phone:612-208-2865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN246161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical