Provider Demographics
NPI:1558984435
Name:MCTEAGUE, MATT T (LISW-S)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:T
Last Name:MCTEAGUE
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 LEAR ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-1280
Mailing Address - Country:US
Mailing Address - Phone:614-767-9401
Mailing Address - Fax:
Practice Address - Street 1:1115 BETHEL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2690
Practice Address - Country:US
Practice Address - Phone:614-767-9401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1801226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty