Provider Demographics
NPI:1861850208
Name:WIGGINS, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WIGGINS
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 1:338 CANNA DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-3821
Mailing Address - Country:US
Mailing Address - Phone:407-569-6960
Mailing Address - Fax:
Practice Address - Street 1:338 CANNA DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-3821
Practice Address - Country:US
Practice Address - Phone:407-569-6960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-30
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1176103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool