Provider Demographics
NPI:1821145335
Name:MATSON, TODD RUSSELL (DMIN)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:RUSSELL
Last Name:MATSON
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E 5TH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2379
Mailing Address - Country:US
Mailing Address - Phone:704-375-5354
Mailing Address - Fax:704-375-3069
Practice Address - Street 1:801 S HAYNE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-6016
Practice Address - Country:US
Practice Address - Phone:704-375-5354
Practice Address - Fax:704-375-3069
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC955101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional