Provider Demographics
NPI:1528515335
Name:MATLOCK, REBECCA (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:CHRISTINE
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:501 ADESA BLVD
Practice Address - Street 2:SUITE A-150
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37771-6725
Practice Address - Country:US
Practice Address - Phone:865-986-8082
Practice Address - Fax:865-986-5890
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10592 (LMSW)104100000X
TNLSW69901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker