Provider Demographics
NPI:1922388271
Name:STECH, MATTHEW W (PPC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:W
Last Name:STECH
Suffix:
Gender:M
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1868
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1868
Mailing Address - Country:US
Mailing Address - Phone:307-733-2046
Mailing Address - Fax:307-733-6289
Practice Address - Street 1:640 E BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-2046
Practice Address - Fax:307-733-6289
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-510101YP2500X
WYLPC-1347101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional