Provider Demographics
NPI:1841763992
Name:WINSLOW, MATTHEW SIMON
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SIMON
Last Name:WINSLOW
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 1:101 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-3602
Mailing Address - Country:US
Mailing Address - Phone:707-961-0172
Mailing Address - Fax:844-388-6167
Practice Address - Street 1:137 E OAK ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-3610
Practice Address - Country:US
Practice Address - Phone:707-345-4012
Practice Address - Fax:844-388-6167
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC41677251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health