Provider Demographics
NPI:1861908337
Name:TOMPKINS, MATTHEW T (LPC, NCC, EDS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:T
Last Name:TOMPKINS
Suffix:
Gender:M
Credentials:LPC, NCC, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E JACKSON BLVD STE B1
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-2400
Mailing Address - Country:US
Mailing Address - Phone:573-213-8033
Mailing Address - Fax:
Practice Address - Street 1:810 E JACKSON BLVD STE B1
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-2400
Practice Address - Country:US
Practice Address - Phone:573-213-8033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017032823101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490055178Medicaid