Provider Demographics
NPI:1154717429
Name:MATSON, HEATHER (LMFT, ATR-BC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MATSON
Suffix:
Gender:F
Credentials:LMFT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 4TH ST E STE 301
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1771
Mailing Address - Country:US
Mailing Address - Phone:651-318-0109
Mailing Address - Fax:651-344-0515
Practice Address - Street 1:275 4TH ST E STE 301
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1771
Practice Address - Country:US
Practice Address - Phone:651-318-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14096221700000X
MN2877106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1154717429Medicaid
MN1801282173Medicaid