Provider Demographics
NPI:1851939565
Name:ZOLLICOFFER, MAT LAVERN
Entity Type:Individual
Prefix:
First Name:MAT
Middle Name:LAVERN
Last Name:ZOLLICOFFER
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 1:1502 N 58TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-4820
Mailing Address - Country:US
Mailing Address - Phone:402-556-6425
Mailing Address - Fax:
Practice Address - Street 1:1502 N 58TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-4820
Practice Address - Country:US
Practice Address - Phone:402-556-6425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1639101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)