Provider Demographics
NPI:1841775772
Name:MATKIN, ELLI MARIE (LCSW, ROLFER)
Entity Type:Individual
Prefix:
First Name:ELLI
Middle Name:MARIE
Last Name:MATKIN
Suffix:
Gender:F
Credentials:LCSW, ROLFER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 SHERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-2301
Mailing Address - Country:US
Mailing Address - Phone:509-540-2418
Mailing Address - Fax:
Practice Address - Street 1:210 N HIGGINS AVE STE 220
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4443
Practice Address - Country:US
Practice Address - Phone:509-540-2418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MTBBH-LCSW-LIC-553111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty