Provider Demographics
NPI:1790783918
Name:REESE, MATTHEW BRADLEY (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRADLEY
Last Name:REESE
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 1:6350 W ANDREW JOHNSON HWY DEPT 100
Mailing Address - Street 2:
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:1596 HIGHWAY 33 S
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825-7104
Practice Address - Country:US
Practice Address - Phone:423-626-2965
Practice Address - Fax:423-626-2968
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW9231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3924910Medicaid
TN3924912Medicare PIN
TN3924910Medicare ID - Type Unspecified