Provider Demographics
NPI:1578549127
Name:MATSON, BILL R (LCSW)
Entity Type:Individual
Prefix:
First Name:BILL
Middle Name:R
Last Name:MATSON
Suffix:
Gender:M
Credentials:LCSW
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 171166
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-1166
Mailing Address - Country:US
Mailing Address - Phone:801-450-8508
Mailing Address - Fax:801-272-1002
Practice Address - Street 1:4055 S 700 E
Practice Address - Street 2:SUITE 102
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2174
Practice Address - Country:US
Practice Address - Phone:810-450-8508
Practice Address - Fax:801-272-1002
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9731070235011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000077093Medicare UPIN
UTS49537Medicare UPIN
UT004662144Medicare PIN