Provider Demographics
NPI:1790352722
Name:CULBRETH, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CULBRETH
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 1:2608 WOODSDALE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220
Mailing Address - Country:US
Mailing Address - Phone:812-756-6029
Mailing Address - Fax:
Practice Address - Street 1:301 GORDON GUTMANN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3765
Practice Address - Country:US
Practice Address - Phone:812-282-4844
Practice Address - Fax:812-282-6248
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017889363LP0808X
IN71011143A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7100766380Medicaid
IN196290262OtherMEDICARE
KY300058907Medicaid