Provider Demographics
NPI:1104233709
Name:MATLOCK, DANIELLE DESSA (LCSW)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:DESSA
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:DESSA
Other - Last Name:STANSBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-0568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1203 AMERICAN GREETING CARD RD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-4811
Practice Address - Country:US
Practice Address - Phone:606-528-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
KY2532571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)