Provider Demographics
NPI:1932449519
Name:ANDERSEN, MATTHEW COLT (LPC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:COLT
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4531
Mailing Address - Country:US
Mailing Address - Phone:208-232-0021
Mailing Address - Fax:208-232-0031
Practice Address - Street 1:495 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4531
Practice Address - Country:US
Practice Address - Phone:208-232-0021
Practice Address - Fax:208-232-0031
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health