Provider Demographics
NPI:1710441829
Name:SISSONS, MATTHEW KEITH (MA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:KEITH
Last Name:SISSONS
Suffix:
Gender:M
Credentials:MA
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 367
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-0367
Mailing Address - Country:US
Mailing Address - Phone:320-639-2025
Mailing Address - Fax:320-200-7527
Practice Address - Street 1:11 2ND ST SW
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1482
Practice Address - Country:US
Practice Address - Phone:320-639-2025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH17584101Y00000X
FLMH21911101Y00000X
MN3929101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor