Provider Demographics
NPI:1972759017
Name:WADSWORTH, MATTHEW J (LCSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:WADSWORTH
Suffix:
Gender:M
Credentials:LCSW
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 306
Mailing Address - Street 2:
Mailing Address - City:FORT HALL
Mailing Address - State:ID
Mailing Address - Zip Code:83203-0306
Mailing Address - Country:US
Mailing Address - Phone:208-237-5631
Mailing Address - Fax:208-237-5796
Practice Address - Street 1:717 MISSION ROAD
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203-0306
Practice Address - Country:US
Practice Address - Phone:208-237-5631
Practice Address - Fax:208-237-5796
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-312811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical