Provider Demographics
NPI:1578750014
Name:MATZELLE, ROBERT DUDLEY
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DUDLEY
Last Name:MATZELLE
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:PO BOX 6005
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-6005
Mailing Address - Country:US
Mailing Address - Phone:307-789-3710
Mailing Address - Fax:307-789-0823
Practice Address - Street 1:2701 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS JUNCTION
Practice Address - State:MD
Practice Address - Zip Code:20701-1017
Practice Address - Country:US
Practice Address - Phone:240-280-3284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY450103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical