Provider Demographics
NPI:1588695860
Name:MATLACK, HEIDI M (LCSW, LAC)
Entity type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:M
Last Name:MATLACK
Suffix:
Gender:F
Credentials:LCSW, LAC
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:M
Other - Last Name:MATLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW, LAC
Mailing Address - Street 1:465 E GALENA ST STE B
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1931
Mailing Address - Country:US
Mailing Address - Phone:406-782-0008
Mailing Address - Fax:
Practice Address - Street 1:465 E GALENA ST STE B
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1931
Practice Address - Country:US
Practice Address - Phone:406-782-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1041C0700XMedicaid
MT1041C0700XMedicaid