Provider Demographics
NPI:1609090471
Name:MATTHEWS, MARK WALKER (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WALKER
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8017 CRAZY HORSE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-4161
Mailing Address - Country:US
Mailing Address - Phone:817-909-3766
Mailing Address - Fax:
Practice Address - Street 1:8017 CRAZY HORSE LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-4161
Practice Address - Country:US
Practice Address - Phone:817-577-5717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31431103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1031619Medicaid
TX1031619Medicaid