Provider Demographics
NPI:1295128270
Name:LITAKER, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LITAKER
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 1:1610 LEISHA DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-1482
Mailing Address - Country:US
Mailing Address - Phone:254-371-4831
Mailing Address - Fax:
Practice Address - Street 1:14138 STATE HIGHWAY 195
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-4850
Practice Address - Country:US
Practice Address - Phone:254-519-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-14
Last Update Date:2015-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70557101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health