Provider Demographics
NPI:1619772779
Name:MYERS, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MYERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15517 CLEARBROOK ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8095
Mailing Address - Country:US
Mailing Address - Phone:317-690-8275
Mailing Address - Fax:
Practice Address - Street 1:1143 E 181ST ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8926
Practice Address - Country:US
Practice Address - Phone:317-480-4002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-13
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-24-333754106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician