Provider Demographics
NPI:1114749249
Name:PEVERILL, MATTHEW R (PHD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:R
Last Name:PEVERILL
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 1:4314 CRITCHELL TER
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-1535
Mailing Address - Country:US
Mailing Address - Phone:857-277-9083
Mailing Address - Fax:
Practice Address - Street 1:700 RAY O VAC DR STE 220
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2476
Practice Address - Country:US
Practice Address - Phone:608-276-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5251-57103TB0200X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent