Provider Demographics
NPI:1851767305
Name:ANGLEMAN, MATTHEW RYAN (MA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:ANGLEMAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:RYAN
Other - Last Name:ANGLEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:414 EAGLE CREST CT
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81507-3307
Mailing Address - Country:US
Mailing Address - Phone:970-549-0183
Mailing Address - Fax:
Practice Address - Street 1:640 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2738
Practice Address - Country:US
Practice Address - Phone:970-549-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
COLPC.0014852101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1982865580Medicaid