Provider Demographics
NPI:1780242974
Name:STANLEY, MATTHEW (PHD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:STANLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30628 DETROIT RD STE 125
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5844
Mailing Address - Country:US
Mailing Address - Phone:440-821-0051
Mailing Address - Fax:
Practice Address - Street 1:30628 DETROIT RD STE 125
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5844
Practice Address - Country:US
Practice Address - Phone:440-821-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.07825103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0407106Medicaid