Provider Demographics
NPI:1659680973
Name:LISTON, MATTHEW BRANDON
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRANDON
Last Name:LISTON
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 1:2215 CORDOVA ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2140
Mailing Address - Country:US
Mailing Address - Phone:503-481-3938
Mailing Address - Fax:
Practice Address - Street 1:4045 LAKE OTIS PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5227
Practice Address - Country:US
Practice Address - Phone:907-561-0954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor