Provider Demographics
NPI:1659725422
Name:MINDRUP, MATTHEW PATTON (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PATTON
Last Name:MINDRUP
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 1:372 HAND DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1915
Mailing Address - Country:US
Mailing Address - Phone:636-327-1219
Mailing Address - Fax:
Practice Address - Street 1:372 HAND DR
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1915
Practice Address - Country:US
Practice Address - Phone:636-327-1219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160084131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical