Provider Demographics
NPI:1629225685
Name:COSTLEY, MATT (PSYD)
Entity Type:Individual
Prefix:MR
First Name:MATT
Middle Name:
Last Name:COSTLEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 E CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-6149
Mailing Address - Country:US
Mailing Address - Phone:417-236-2600
Mailing Address - Fax:417-236-2619
Practice Address - Street 1:2200 E CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-6149
Practice Address - Country:US
Practice Address - Phone:417-236-2600
Practice Address - Fax:417-236-2619
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010032191103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical