Provider Demographics
NPI:1720257694
Name:MATSON, WARREN BRUCE (MSED, LCPC)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:BRUCE
Last Name:MATSON
Suffix:
Gender:M
Credentials:MSED, LCPC
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 921
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-0921
Mailing Address - Country:US
Mailing Address - Phone:630-871-0770
Mailing Address - Fax:630-871-0772
Practice Address - Street 1:208 N WEST ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5098
Practice Address - Country:US
Practice Address - Phone:630-871-0770
Practice Address - Fax:630-871-0772
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-002341101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional