Provider Demographics
NPI:1639941925
Name:BACK, MATTHEW JAMES
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:BACK
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 1:331 W 2700 S
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2904
Mailing Address - Country:US
Mailing Address - Phone:801-678-3317
Mailing Address - Fax:
Practice Address - Street 1:331 W 2700 S
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-2904
Practice Address - Country:US
Practice Address - Phone:801-678-3317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11705657-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical