Provider Demographics
NPI:1902079478
Name:MATRIX INTEGRATED PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:MATRIX INTEGRATED PSYCHOLOGICAL SERVICES
Other - Org Name:MATRIX PSYCHOLOGICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:MALKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:614-475-9500
Mailing Address - Street 1:2 EASTON OVAL
Mailing Address - Street 2:STE 450
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-6036
Mailing Address - Country:US
Mailing Address - Phone:614-475-9500
Mailing Address - Fax:614-475-9821
Practice Address - Street 1:2 EASTON OVAL
Practice Address - Street 2:STE 450
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6036
Practice Address - Country:US
Practice Address - Phone:614-475-9500
Practice Address - Fax:614-475-9821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YA0400X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty