Provider Demographics
NPI:1558759522
Name:DEETS, MATTHEW JOHN (LPC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOHN
Last Name:DEETS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 118
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54402-0118
Mailing Address - Country:US
Mailing Address - Phone:715-675-3458
Mailing Address - Fax:715-675-7238
Practice Address - Street 1:741 N 1ST ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-4721
Practice Address - Country:US
Practice Address - Phone:715-675-3458
Practice Address - Fax:715-675-7238
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1801-226101YM0800X
WI5814-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5814-125OtherSTATE LICENSE
WI1801-226OtherSTATE LICENSE