Provider Demographics
NPI:1548390560
Name:DOLL, MATTHEW D (PHD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
Last Name:DOLL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 SHEBOYGAN ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4364
Mailing Address - Country:US
Mailing Address - Phone:920-923-0082
Mailing Address - Fax:
Practice Address - Street 1:40 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8049
Practice Address - Country:US
Practice Address - Phone:920-907-8201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1691-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPO6498Medicare ID - Type UnspecifiedMEDICARE