Provider Demographics
NPI:1558939678
Name:GROVENSTEIN, MATTHEW AIAH
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:AIAH
Last Name:GROVENSTEIN
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 1:1949 SUGARLAND DR
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-5755
Mailing Address - Country:US
Mailing Address - Phone:307-429-2356
Mailing Address - Fax:
Practice Address - Street 1:1949 SUGARLAND DR
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5755
Practice Address - Country:US
Practice Address - Phone:307-429-2356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-2146101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional